The Oxford Handbook of the History of Medicine 9780199546497, 0199546495

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t h e ox f o r d h a n d b o o k o f

T H E H ISTORY OF M E DICI N E

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the oxford handbook of

THE HISTORY OF MEDICINE

Edited by

MARK JACKSON

1

1

Great Clarendon Street, Oxford ox dp Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York The editorial Material and Arrangement © the Editor 2011 The chapters © the various contributors 2011 The moral rights of the authors have been asserted Database right Oxford University Press (maker) First published 2011 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Data available Typeset by SPI Publisher Services, Pondicherry, India Printed in Great Britain on acid-free paper by MPG Books Group, Bodmin and King’s Lynn ISBN ––––          

Acknowledgements

The production of this volume has been a genuine team effort. The idea for an Oxford Handbook of the History of Medicine originated with Christopher Wheeler at Oxford University Press. I am deeply grateful to Christopher both for his initial vision for the volume and for his support throughout the long and complicated process of production. I am also indebted to Christopher’s assistants, Natasha Knight, Jenny Townshend, Stephanie Ireland, and Emma Barber, who have guided me through the editorial challenges and managed the website with energy and accuracy. Of course, the volume would not have materialized without the commitment, knowledge, and skill of the contributors—it has been a pleasure dealing with them and generating what we hope will prove to be a pivotal text within the field. We are grateful to a variety of sources for the illustrations. Figure 1 in Chapter 21 was compiled from the following sources: E. A. Wrigley, R. S. Davies, J. E. Oeppen, and R. S. Schofield, English Population History from Family Reconstitution 1580–1837 (Cambridge: Cambridge University Press, 1997), Table 6.27, 308; Office for National Statistics, Mortality Statistics: General Review of the Registrar-General on Deaths in England and Wales, 1998: Series DH1 No. 31 (London: The Stationery Office); and Office for National Statistics, Interim Life Tables, England & Wales, 1980–82 to 2006–08, available at http:// www.statistics.gov.uk/downloads/theme_population/Interim_Life/ILTEW0608Reg. xls. The illustration in Chapter 22 is from Royal College of Physicians, Smoking and Health: Summary and Report of the Royal College of Physicians of London on Smoking in Relation to Cancer of the Lung and other Diseases (London: Pitman, 1962), 15, copyright © 1962 Royal College of Physicians, reproduced by permission. Figures 1 and 2, and Table 1 in Chapter 24 were compiled by the author from data available from OECD Health Data 2008—Selected Data, available at http://stats.oecd.org/index.aspx. The cover illustration is reproduced by permission of the Wellcome Library, London, and I am grateful to Rachael Johnson, Wellcome Images, for her help. I am grateful to the Wellcome Trust not only for funding many of my own research endeavours in the history of medicine, but also for energizing the discipline over recent decades: in particular, I thank Mark Walport, Clare Matterson, Tony Woods, Liz Shaw, Nils Fietje, Emma Young, and Sue Crossley for their support and friendship. I also thank Claire Keyte, administrator for the Centre for Medical History at the University of Exeter, for providing invaluable support during the challenging early stage of commissioning chapters, and Kathie Gill and Linda Smith for their meticulous proof-reading. Closer to home, Siobhán, Ciara, Riordan, and Conall remain my inspiration and salvation; more than anybody, they remind me, daily, of the personal and political significance of promoting health and happiness.

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Contents

List of Illustrations and Tables List of Contributors

1. Introduction

x xi 1

Mark Jackson

PA RT I PE R IODS 2. Medicine and Health in the Graeco-Roman World

21

Philip van der Eijk

3. Medieval Medicine

40

Peregrine Horden

4. Early Modern Medicine

60

Thomas Rütten

5. Health and Medicine in the Enlightenment

82

E. C. Spary

6. Medicine and Modernity

100

Roger Cooter

7. Contemporary History of Medicine and Health

117

Virginia Berridge

PA RT I I PL ACE S A N D T R A DI T IONS 8. Global and Local Histories of Medicine: Interpretative Challenges and Future Possibilities

135

Sanjoy Bhattacharya

9. Chinese Medicine Vivienne Lo and Michael Stanley-Baker

150

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contents

10. Medicine in Islam and Islamic Medicine

169

Hormoz Ebrahimnejad

11. Medicine in Western Europe

190

Harold J. Cook

12. History of Medicine in Eastern Europe, Including Russia

208

Marius Turda

13. Science and Medicine in the United States of America

225

Edmund Ramsden

14. Public Health and Medicine in Latin America

243

Anne-Emanuelle Birn

15. History of Medicine in Sub-Saharan Africa

266

Lyn Schumaker

16. Medicine and Colonialism in South Asia since 1500

285

Mark Harrison

17. History of Medicine in Australia and New Zealand

302

Linda Bryder

PA RT I I I T H E M E S A N D M ET HODS 18. Childhood and Adolescence

321

Alysa Levene

19. Medicine and Old Age

338

Susannah Ottaway

20. Death

355

Julie-Marie Strange

21. Historical Demography and Epidemiology: The Meta-Narrative Challenge

373

Graham Mooney

22. Chronic Illness and Disease History

393

Carsten Timmermann

23. Public Health Christopher Hamlin

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contents

24. The Political Economy of Health Care in the Nineteenth and Twentieth Centuries

ix

429

Martin Gorsky

25. Health, Work, and Environment: A Hippocratic Turn in Medical History

450

Christopher Sellers

26. History of Science and Medicine

469

Staffan Müller-Wille

27. Women, Health, and Medicine

484

Hilary Marland

28. Health and Sexuality

503

Gayle Davis

29. Medicine and the Mind

524

Rhodri Hayward

30. Medical Ethics and the Law

543

Andreas-Holger Maehle

31. Medicine and Species: One Medicine, One History?

561

Robert G. W. Kirk and Michael Worboys

32. Histories of Heterodoxy

578

Roberta Bivins

33. Oral Testimony and the History of Medicine

598

Kate Fisher

34. Medical Film and Television: An Alternative Path to the Cultures of Biomedicine

617

Timothy Boon

Index

635

List of Illustrations and Tables

Illustrations 21.1

Life expectation at birth (e0) and female/male life expectation at birth ratio, England and Wales, 1625–2008. 22.1 A different perspective on what has come to be known as the epidemiologic transition: death rates from cancer, tuberculosis and bronchitis among middle-aged men in England and Wales, 1916–1959. 24.1 Per capita health expenditure in selected developed nations, US$ (purchasing power parity) at constant prices (1983). 24.2 Health expenditure as percentage of GDP in selected developed nations.

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Tables 24.1

Population health indicators in selected developed nations.

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List of Contributors

Virginia Berridge is Professor of History at the London School of Hygiene and Tropical Medicine and Director of the Centre for History in Public Health. She has worked in both historical and non-historical academic settings, and also as a non-historian, as scientific secretary to a drug addiction research initiative. Sanjoy Bhattacharya is a Reader at the Department of History at the University of York (UK). Sanjoy’s work deals with the history of global and international health programmes in South Asia and beyond and he is currently engaged in completing two monographs dealing with the eradication of smallpox in Bangladesh and Afghanistan, respectively. Sanjoy is closely associated with the World Health Organization’s Global Health Histories initiative and he has an active interest in global health policy assessment (he is involved in assessing the social determinants of vaccine-preventable diseases in the developing and less developed world). Anne-Emanuelle Birn is Professor and Canada Research Chair in International Health, University of Toronto. She is the author of Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (University of Rochester Press, 2006) and lead author of the Textbook of International Health: Global Health in a Dynamic World, 3rd edn (Oxford University Press, 2009). Roberta Bivins is an Associate Professor of History at the University of Warwick. She has written several books on cross-cultural and heterodox medicine, and is now studying the reciprocal impacts of post-colonial immigration and medical research in the United States and Britain. Tim Boon is Chief Curator at the UK’s Science Museum, where he is responsible for the team of specialist subject curators and is a member of the Museum’s senior management team. He has been an active exhibition curator; displays include Health Matters (1994), Making the Modern World (2000), Treat Yourself (2003), and Films of Fact: The Origins of Science on Screen (2008). He studied History and History of Science at Leeds University and University College London. His doctorate was awarded in 1999 for Films and the Contestation of Public Health in Interwar Britain. He has spoken and published extensively on the use of films and television in science and medicine. His first monograph, Films of Fact: A History of Science in Documentary Films and Television (Wallflower Press), was published in 2008. He is currently running a project on the public history of science, technology, and medicine.

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Linda Bryder is Professor of History at the University of Auckland and Fellow of the Royal Society of New Zealand and holds an Honorary Chair at the London School of Hygiene and Tropical Medicine. She has published widely in the history of public health in the twentieth century, including three monographs: Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain (1988); A Voice for Mothers: The Plunket Society and Infant Welfare, 1907–2000 (2003); and Women’s Bodies and Medical Science: An Inquiry into Cervical Cancer (2010). She is currently on the editorial boards of Medical History and Health and History, and is President of the Australian and New Zealand Society of the History of Medicine. Harold J. Cook has taught and held administrative positions at Harvard, the University of Wisconsin-Madison, and the Wellcome Trust Centre for the History of Medicine at University College London, and is now developing the history of medicine at Brown University. He publishes mainly on medicine in early modern Europe, with particular attention to England and the Netherlands and with an interest in seeing how the scientific revolution was shaped by the medical community. He helped to pioneer the method of studying the medical marketplace and most recently published an award-winning book on medicine, science, and commerce in the Dutch Golden Age, Matters of Exchange (2007). Roger Cooter is a Professorial Fellow at the Wellcome Trust Centre for the History of Medicine at University College London. His publications include: The Cultural Meaning of Popular Science (1984); In the Name of the Child: Health and Welfare, 1880–1940 (ed., 1992); Surgery and Society in Peace and War: Orthopaedics and the Organization of Modern Medicine, 1880–1948 (1993); and, with J. V. Pickstone, Medicine in the Twentieth Century (eds, 2000). Gayle Davis is Wellcome Lecturer in the History of Medicine at the University of Edinburgh. Her current research examines the social, medical, and political response to infertility in later-twentieth-century Scotland. Her published work includes: ‘The Cruel Madness of Love’: Sex, Syphilis and Psychiatry in Scotland, 1880–1930 (2008); ‘Stillbirth Registration and Perceptions of Infant Death, 1900–60: The Scottish Case in National Context’, Economic History Review, 62:3 (2009), 629–54; and the forthcoming The Sexual State: Sexuality and Scottish Governance, 1950–1980, jointly authored with Roger Davidson. Hormoz Ebrahimnejad is Wellcome Trust Lecturer in History at the Faculty of Humanities, University of Southampton. His doctoral research was on power structures in eighteenth- and nineteenth-century Iran. His current research in the history of medicine covers issues such as the relationship between medicine and power, the impacts of institutions on scientific developments, and the emergence of the medical profession and hospital institutions and their relationship with medical knowledge in both medieval and modern periods. His publications include Medicine, Public Health and the Qâjâr State: Patterns of Medical Modernization in Nineteenth-Century Iran. He is currently

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working on the transition from traditional to modern medicine in nineteenth- and twentieth-century Iran. Philip van der Eijk read classics and comparative literature at Leiden University, where he was awarded his PhD in 1991. After a research fellowship funded by the Netherlands Organisation of Scientific Research, he moved to Newcastle University to take up a Wellcome Trust University Award in the History of Medicine in the Classical World. In 1998 he was appointed Professor of Greek at Newcastle, in 2005 Research Professor. With colleagues in Newcastle and Durham, he founded the Northern Centre of the History of Medicine in 2003, of which he was a Director until 2009. In 2010, he moved to the Humboldt University in Berlin to take up an Alexander von Humboldt Professorship in Classics and History of Science. His publications include: Diocles of Carystus: A Collection of the Fragments with Translation and Commentary, 2 vols (2000–1); Medicine and Philosophy in Classical Antiquity: Doctors and Philosophers on Nature, Soul, Health and Disease (2005); Aristoteles. De insomniis. De divinatione per somnum (1994); Philoponus, On Aristotle on the Soul 1, 2 vols (2005–6); Nemesius of Emesa, On the Nature of Man, with R. W. Sharples (2008); Ancient Histories of Medicine: Essays in Medical Doxography and Historiography in Classical Antiquity (ed., 1999); Hippocrates in Context (ed., 2005); Ancient Medicine in Its Socio-Cultural Context, co-edited with H. F. J. Horstmanshoff and P. H. Schrijvers, 2 vols (1995). Kate Fisher is Senior Lecturer in History at the University of Exeter and currently Director of the Centre for Medical History. She is the author of two books drawing upon oral testimony, Birth Control, Sex and Marriage in Britain, 1918–1960 (Oxford: Oxford University Press, 2006) and, with Simon Szreter, Sex before the Sexual Revolution: Intimate Life in Britain, 1918–1963 (Cambridge: Cambridge University Press, 2010). Martin Gorsky is Senior Lecturer in the Contemporary History of Public Health in the Centre for History in Public Health at the London School of Hygiene and Tropical Medicine. His research interests lie in the history of public health and health services in Britain, Europe, and America in the nineteenth and twentieth centuries and he has published widely on the development of the British voluntary hospitals and of mutual associations such as friendly societies and hospital contributory schemes. Amongst his current research projects are a study of the history of management in the British NHS, a history of the public health poster in twentieth-century Poland, the construction and analysis of morbidity indices derived from sickness insurance records, and the performance of health services under local government in interwar Britain. Christopher Hamlin is Professor in the Department of History and the Program in History and Philosophy of Science at the University of Notre Dame and Honorary Professor in the Department of Public Health and Policy at the London School of Hygiene and Tropical Medicine. He works on multiple issues in the history of public health, the social history of science, and environmental history. His most recent book is Cholera: The Biography (2009).

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Mark Harrison is Professor of the History of Medicine and Director of the Wellcome Unit for the History of Medicine at the University of Oxford. He is the author of many books and articles on the history of disease, medicine, and colonialism, including Public Health in British India (1994), Climates and Constitutions (1999), and, with Sanjoy Bhattacharya and Michael Worboys, Fractured States: Smallpox, Public Health and Vaccination Policy 1800–1947 (2006). He is editor, with Biswamoy Pati, of Health, Medicine and Empire: Perspectives on Colonial India (2001) and The Social History of Health and Medicine in British India (2009), and, with Margaret Jones and Helen Sweet, of From Western Medicine to Global Medicine: The Hospital Beyond the West (2009). Rhodri Hayward is Wellcome Award Lecturer in the History of Medicine at Queen Mary, University of London. His current research examines the rise and political implications of psychiatric epidemiology in modern Britain. He has previously published on the history of dreams, Pentecostalism, demonology, cybernetics, and the relations between psychiatry and primary care. Peregrine Horden is Professor of Medieval History at Royal Holloway, University of London, and an Extraordinary Research Fellow of All Souls College, Oxford. He has written extensively on the social history of late antique and medieval medicine, the history of hospitals and of music therapy, and environmental history. His recent publications include Hospitals and Healing from Antiquity to the Later Middle Ages (2008). Mark Jackson is Professor of the History of Medicine at the University of Exeter and was Director of the Centre for Medical History there between 2000 and 2010. He served as Chair of the Wellcome Trust History of Medicine Funding Committee between 2003 and 2008 and is currently Chair of the Wellcome Trust Research Resources in Medical History Funding Committee. He has taught modules in the history of medicine and the history and philosophy of science for over twenty years at undergraduate and postgraduate levels to both medical and history students, and has also been involved in teaching medical history to GCSE and A-level students. His books include Newborn Child Murder (1996), The Borderland of Imbecility (2000), Infanticide: Historical Perspectives on Child Murder and Concealment 1550–2000 (ed., 2002), Allergy: The History of a Modern Malady (2006), Health and the Modern Home (ed., 2007), and Asthma: The Biography (2009). The Age of Stress: Science and the Search for Stability is due to be published by Oxford University Press in 2012. Robert G. W. Kirk joined the Centre for the History of Science, Technology, and the Medicine and Wellcome Unit for the History of Medicine at the University of Manchester in 2006, having completed a PhD in the history of medicine at University College London. He is a historian of twentieth-century medicine, the biomedical sciences, and bioethics, with specific interest in the place of non-human animals in such histories. His research explores the development of animal experimentation in Britain, tracing how animal welfare became a scientific and moral necessity within as much as without the laboratory. By tracing the changing development of laboratory practice alongside shifts

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in wider public and antivivisectionist thought (which, together, shaped the emergence of the ‘animal rights’ movement in the 1970s), this work will historicize the formation of the now dominant utilitarian form of reasoning that governs contemporary animal experimental practice. He is also working on the history of the medicinal leech, and is beginning a new project on the relationships between laboratory and clinical practice in the development of psychopharmacology. Alysa Levene is a Senior Lecturer in Early Modern History at Oxford Brookes University. She works on the history of child health and welfare, particularly on poor children in London, children as hospital patients, and pauper apprenticeship. She is particularly concerned with the ways that children were treated by doctors and poor law officers as a separate group of patients/paupers, and how this relates to changing ideas about childhood. Her published work includes Childcare, Health and Mortality at the London Foundling Hospital, 1741–1800: ‘Left to the mercy of the world’ (2007); ‘Pauper Apprenticeship and the Old Poor Law in London: Feeding the Industrial Economy?’ (Economic History Review, 63 (2010), 915–41); and ‘Poor Families, Removals and “Nurture” in Late Old Poor Law London’ (Continuity and Change, 25 (2010), 233–62). She has also worked on twentieth-century medical history and is a joint author of Cradle to Grave: Municipal Medicine in Inter-war England and Wales (2010). Vivienne Lo is Convenor of the UCL China Centre for Health and Humanity. She is a practitioner of Chinese medicine and martial arts and has published widely on ancient and medieval Chinese healing practices. She is the editor, with Chrisopher Cullen, of Mediaeval Chinese Medicine (2005) and, with Geoffrey Samuel, of the Journal Asian Medicine: Tradition and Modernity (2005–2011). Potent Flavours, Food and Medicine in China and Sports, Medicine and Immortality are due to be published in 2012. Andreas-Holger Maehle is Professor of the History of Medicine and Medical Ethics at Durham University (UK), where he directs the Centre for the History of Medicine and Disease. He has published widely on the history of experimental medicine and of medical ethics, including: Johann Jakob Wepfer (1620–1695) als Toxikologe (1987); Kritik und Verteidigung des Tierversuchs: Die Anfänge der Diskussion im 17. und 18. Jahrhundert (1992); Drugs on Trial: Experimental Pharmacology and Therapeutic Innovation in the Eighteenth Century (1999); Historical and Philosophical Perspectives on Biomedical Ethics (ed. with J. Geyer-Kordesch, 2002); A Short History of the Drug Receptor Concept, with C.-R. Prüll and R. F. Halliwell (2009); and Doctors, Honour and the Law: Medical Ethics in Imperial Germany (2009). Hilary Marland is Professor of History at the University of Warwick and Director of the Institute of Advanced Study. She is former editor of Social History of Medicine and from 2003 to 2008 was Director of the Centre for the History of Medicine at Warwick. She has published on the history of midwifery and childbirth, infant welfare, women and medical practice, alternative medicine, hydropathy, and women and madness. In 2004 she published Dangerous Motherhood: Insanity and Childbirth in Victorian Britain and is

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currently writing a study of girls’ health in late nineteenth- and early-twentieth-century Britain. She is also collaborating on two new projects: madness, migration, and the Irish in Lancashire, c.1850–1921; and domestic medical practices and technologies in the modern period. Graham Mooney is an Assistant Professor in the Institute of the History of Medicine at Johns Hopkins University, where he teaches the history of public health. He has published numerous articles on historical mortality and epidemiological change in nineteenth- and twentieth-century Britain. He co-edited with Jonathan Reinarz Permeable Walls: Historical Perspectives on Hospital and Asylum Visiting (2009) and is writing a book on infectious disease surveillance in Victorian England. He is currently co-editor of Social History of Medicine. Staffan Müller-Wille is Senior Lecturer at the University of Exeter and associated with the ESRC Centre for Genomics in Society and the Centre for Medical History. He received his PhD in philosophy from the University of Bielefeld (Germany) and has previously worked for the German Hygiene Museum, Dresden, and the Max-PlanckInstitute for the History of Science, Berlin. He has published extensively on the history of heredity and genetics. Among his most recent publications is a book in German, Vererbung. Geschichte und Kultur eines biologischen Konzepts, which is currently being translated into English for University of Chicago Press. Susannah Ottaway is an Associate Professor of History at Carleton College, having earned her PhD at Brown University in 1998, and since then has lived in Northfield, Minnesota (USA). She published The Decline of Life: Old Age in Eighteenth-Century England (2004) and is currently at work on a book on the British workhouse in the ‘long’ eighteenth century. Edmund Ramsden is a Research Fellow in the Centre for Medical History at the University of Exeter, working on a Wellcome Trust-funded project on the history of stress. His research interests are in the history and sociology of the social and biological sciences and their relations, with a particular focus on the behavioural and population sciences. He is currently completing a book on the history of eugenics, population control, and the population sciences, and writing a book on crowding, stress, and the built environment in the twentieth-century United States. Thomas Rütten is a licensed physician, a Reader in the History of Medicine, and currently the Director of the Newcastle branch of the Northern Centre for the History of Medicine. He worked in academia in Münster (University), Venice (Centro Tedesco di Studi Veneziani), Wolfenbüttel (HAB), Princeton (IAS), and Paris (VII) before coming to Newcastle in 2002. He has published extensively on ancient, early modern, and eighteenth- and twentieth-century Western medicine. His publications include: Demokrit—lachender Philosoph und sanguinischer Melancholiker (1992); Ars Medica— verlorene Einheit der Medizin? (ed., 1994); ‘Ihr sehr ergebener Thomas Mann’ (ed.,

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2006); Geschichten vom Hippokratischen Eid (2007); and Geschichte der Medizingeschichtsschreibung (ed., 2009). He is sole editor of Medizingeschichtsschreibung, published by Gardez! Lyn Schumaker completed her PhD in history and sociology of science, technology, and medicine at the University of Pennsylvania in 1994, with previous training in anthropology and African history at Michigan State University. Her book, Africanizing Anthropology: Fieldwork, Networks, and the Making of Cultural Knowledge in Central Africa, was published in 2001 by Duke University Press. She worked at the Wellcome Unit for the History of Medicine at Manchester, 1994–2009, receiving a Wellcome Trust University Award in 1999 for research in the history of indigenous, mission, and mining medicine on Zambia’s colonial Copperbelt. Her recent work situates anti-retroviral therapy in the history of Western pharmaceuticals and indigenous medicines in Zambia as well as exploring African perspectives on privately funded medical philanthropy, such as the Bill and Melinda Gates Foundation’s funding of malaria, tuberculosis, and HIV/AIDS research and mining magnate A. Chester Beatty’s funding of early malaria research. Christopher Sellers, MD, PhD, is an environmental and medical historian at Stony Brook University in New York. He is the author of Hazards of the Job: From Industrial Disease to Environmental Health Science (1997) and of the forthcoming Unsettling Ground: Suburban Nature and Environmentalism in Twentieth-Century America, as well as numerous essays and edited volumes. He is currently beginning a comparative history of industrial hazards in the United States and Mexico. E. C. Spary is a lecturer at the Faculty of History, University of Cambridge. She obtained her PhD from the University of Cambridge in 1993, and then worked first at the University of Warwick and later at the Max-Planck-Institut für Wissenschaftsgeschichte, Berlin. She is the author of Utopia’s Garden: French Natural History from Old Regime to Revolution (2000). In addition, she has published numerous shorter pieces and has jointly edited two collections of essays on the history of natural history and one on the history of chemistry. She is currently at work on a history of food and the sciences during the ‘long’ eighteenth century, to be entitled Eating the Enlightenment in Paris. Her research interests include natural history, medicine, diet, health, chemistry, agriculture, and European cultural history in general from the late seventeenth century to the 1810s. Michael Stanley-Baker is currently a Chiang Ching-Kuo doctoral fellow at the Wellcome Trust Centre for the History of Medicine at UCL. He is finishing his PhD dissertation Daoists as Doctors: The Role of Medicine in Six Dynasties Shangqing Daoism, scheduled for submission in the autumn of 2011. He has pursued research at the Needham Research Institute, Cambridge, and the Institute for History and Philology, Taipei, and his MA is from Indiana University, Bloomington, Department of East Asian Languages and Cultures. He currently serves as treasurer of the International Association for the Study of Traditional Asian Medicine (IASTAM). He has published

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on Daoist medicine and Buddhist drug recipes, and his next project will be an edited volume on religion and technology in medieval China. He also does ethnographic work in Mainland China and on Taiwan, and is a certified practitioner (DiplAC)of Chinese medicine. Julie-Marie Strange is Senior Lecturer in Victorian Studies at the University of Manchester. She published Death, Grief and Poverty in Britain, 1870–1914 (Cambridge University Press) in 2005 and is currently working on an ESRC-funded project ‘Families Need Fathers? Paternity and Emotion in Working-Class Culture, 1870–1910’. Carsten Timmermann is a lecturer in the Wellcome Unit for the History of Medicine at the University of Manchester. He has worked on the history of medicine in interwar Germany and most recently on medical science and technology in twentieth-century Britain. He has published on the histories of high blood pressure and lung cancer. Marius Turda is a Reader in Central and Eastern European Biomedicine at Oxford Brookes University. He is the author of The Idea of National Superiority in Central Europe, 1880–1918 and Modernism and Eugenics, and the editor, with Paul Weindling, of Blood and Homeland: Eugenics and Racial Nationalism in Central and Southeast Europe, 1900– 1940. His main areas of interest include the history of eugenics, racism, anthropology, and nationalism in Eastern Europe, with a particular focus on Hungary and Romania. He is currently completing a book on the history of eugenics in Hungary between 1904 and 1944. Michael Worboys is Director of the Centre for the History of Science, Technology, and Medicine and Wellcome Unit for the History of Medicine at the University of Manchester. He continues to work on the history of colonial science and medicine, the history of infectious diseases, and the development of the biomedical sciences. His most recent publications are Mad Dogs and Englishmen: Rabies in Britain, 1830–2000 (2007), coauthored with Neil Pemberton, and a collection, co-edited with Flurin Condrau, entitled Tuberculosis Then And Now: Perspectives on the History of an Infectious Disease (2010). He is starting new work on pedigree dog breeding in Victorian Britain and the recent history of laboratory-clinic relations.

chapter 1

i n troduction m ark jackson

The past is never dead. It’s not even past. William Faulkner, Requiem for a Nun (1953)

This Handbook has two main aims. In the first instance, it looks backwards in order to provide not only a constructive analysis of developments in medical knowledge and practice at different moments in time and in different places, but it also gives a critical account of shifting approaches to prominent theoretical, conceptual, and methodological issues within the history of medicine in recent decades. Individual contributions thus explore and contextualize particular patterns of health, disease, experience, and expertise in the past as well as identifying and reflecting on the diverse historiographical trends that have characterized and shaped both past and present scholarship. From this perspective, the Handbook is intended to offer readers a synthetic account of the state of the art, an opportunity to take stock of where the history of medicine has been and where it now resides. There is, however, a second aim of this volume. In the process of reviewing the chronological, geographical, and thematic coverage and the historiographical achievements of previous scholarship, contributors have also been encouraged to look forwards and to consider how the history of medicine might develop in the future. Particularly in their conclusions, individual chapters thus attempt to establish, and promote discussion about, some of the major challenges facing future historians of medicine in terms of the questions, sources, and methods that should direct and animate the evolution of the discipline. In this context, the Handbook hopes to provide both seasoned and aspiring scholars with a substantial empirical and theoretical platform for future research and with a constructive basis for more informed discussion of the intellectual place and ideological purpose of medical history. Of course, this is not the first book to attempt an overview of this nature. Approximately twenty years ago, Bill Bynum and Roy Porter’s magisterial Companion Encyclopedia of the History of Medicine set out on much the same journey.1 Recognizing the ‘extraordinary rapidity’ with which the history of medicine had developed during

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the second half of the twentieth century, Bynum and Porter’s edited volume brought together over seventy essays by leading historians, clinicians, and social scientists exploring a wide range of subjects within, and approaches to, the history of medicine. The resulting two-volume publication provided an invaluable route map for many of the current generation of scholars, productively establishing some of the principal themes and approaches infecting historical studies of the art and science of medicine in past societies. Although some of the contributions offered relatively unreflective accounts of medical progress and although the editors quite rightly pointed to the importance of tracing ‘long-term chains of connection and the transformations of scientific paradigms’ even at the risk of ‘organizational artificiality and anachronism’, Bynum and Porter largely succeeded in avoiding ‘grossly Whiggish or anachronistic categorizations’ and effectively incorporated the recent insights of social and cultural historians.2 In some ways, much has changed since Bynum and Porter’s pivotal intervention in 1992. Partly prompted by the impetus generated by the Companion Encyclopedia, there is now a substantially larger body of available historical scholarship, which not only explores a far wider and richer array of topics and themes in medical history, but also increasingly analyses and problematizes the conceptual foundations and political imperatives of the history of medicine as a discipline. In recent years, as well as publishing highly focused and carefully contextualized case studies of medical knowledge and practice in the past, historians of medicine throughout the world have also written textbooks designed for undergraduate history and medical students, popular accounts of scientific and clinical developments in medicine, and methodological manifestos intended to transform or energize the field.3 Some of the historians responsible for the significant extension of the disciplinary boundaries of medical history and for the growth of interdisciplinary studies of illness and health care in recent decades are represented in this Handbook. In order to understand this process of expansion (or, some might argue, fragmentation) within the history of medicine, a number of edited collections have, like Bynum and Porter’s earlier work, attempted to provide reflective overviews of developments and debates within the field. Most notable amongst these recent contributions are two provocative collections of essays: Medicine in the Twentieth Century, edited by Roger Cooter and John Pickstone; and Locating Medical History: The Stories and Their Meanings, edited by Frank Huisman and John Harley Warner. Arguing that ‘the history of medicine is integral to the history of the [twentieth] century’, but also that previous historical characterizations of the period require revision, Cooter and Pickstone capitalize on the growing interest amongst historians to explore the political and professional dynamics of modern (rather than ancient, medieval, or early modern) medicine in greater depth: three discrete sections explore in turn the ‘political-economic systems under which medicine has been organized by nation states’ (Power), the ‘changing concepts, representations, and discursive frameworks of medicine’ (Bodies), and the ‘major sites where medicine has been encountered in the twentieth century’ (Experiences). Significantly, and perhaps controversially in the light of the discussion later in this chapter, Cooter

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and Pickstone are prepared to insist that, although history is about the past, ‘its interpretations are driven by the conceptual frameworks and political agendas of the present’.4 The volume edited by Huisman and Warner is no less thought-provoking. Focusing exclusively on how the history of medicine has been written, rather than on medical knowledge and practice in the past, distinct sections trace the contours of ‘traditional’ medical history (a notion that Huisman and Warner effectively dispute), methodological transformations in the field since the 1970s, and ‘some of the divergent directions it seemed to be headed after the cultural turn’.5 The result is a series of energetic, and sometimes deliberately contrasting, interpretations of the methods and meanings of the history of medicine, at least within the Western academic world. One of the central messages that emerges from this collection is that ‘medical history is not a monolith and never has been’; indeed, it is evident from the editors’ introductory discussion of the development of medical history in Germany not only that the field has always been methodologically diverse but also that it has been perpetually riven by disagreements about the precise purpose and place of history. As will become apparent, many of the recent disputes about disciplinary ownership of the field or about the most constructive methodological perspective replicate to some degree these earlier arguments about how medical history should be defined and about who might be best placed to pursue it. This Handbook constitutes an attempt to combine the insights and approaches evident in these recent collective perspectives. Exploring historical developments as well as historiographical trends, individual chapters outline the paths that both medicine and history have taken in the past and, in the process, establish some of the emergent challenges for the future. Within that overall context, the purpose of this introductory chapter is to provide a constructive framework for understanding the complex evolution and topography of the field. Drawing on the contributions themselves, as well as on a substantial body of scholarship published since Bynum and Porter’s encyclopaedic overview of the discipline, the Introduction aims to evaluate recent, occasionally strident, debates about the methods and meanings of medical history, to reflect on the possible role or relevance of history in the twenty-first century, and to set out the intellectual convictions and structural decisions that have shaped this volume.

In search of meanings and methods In May 1970, Thomas McKeown (1911–88), Professor of Social Medicine at the University of Birmingham Medical School, presented the inaugural lecture at the first meeting of the Society for the Social History of Medicine (SSHM), held at the Wellcome Institute for the History of Medicine in London. This meeting was not the first evidence of the gradual institutionalization of medical history in Britain, or indeed elsewhere, during the twentieth century. In 1965, the British Society for the History of Medicine (BSHM) had been established as a joint venture between the Royal Society of Medicine, the Worshipful Society of Apothecaries, the Scottish Society of the History of Medicine, and

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the Osler Club of London, the last two having already been collaborating since 1957 in the production of a quarterly journal, Medical History.6 Three years after the BSHM was founded, the library and museum of the Wellcome Trust were combined to form the Wellcome Institute for the History of Medicine, which, from 1972, incorporated an academic research unit. Similar processes of amalgamation and institutionalization had already been under way elsewhere in the world since the interwar years: in North America, for example, the Institute for the History of Medicine at the Johns Hopkins School of Medicine was founded in 1929 and began to publish the Bulletin of the History of Medicine, the official journal of the American Association for the History of Medicine, ten years later; and in mainland Europe, journals, societies, and chairs in medical history had been established during the first decade or so of the twentieth century.7 Although clearly not the first indication of growing academic interest in the history of medicine, the initial meeting of the SSHM in 1970 was nevertheless significant in provoking a debate that has continued to shape, and indeed divide, scholarship in the field. An ardent advocate of the view that socioeconomic conditions, rather than advances in medicine or public health, were primarily responsible for declining mortality rates and rising population in modern Britain, McKeown argued that much medical history was ‘sterile’, partly because it focused too rigidly on ‘great men and great movements’, rather than on social context, but more particularly because it failed to ‘take its terms of reference from difficulties confronting medicine in the present day’.8 Whether focusing on the patterns and determinants of health and disease in the past, the history of medical treatment and public health initiatives, or the evolution of hospital and general practice, McKeown suggested that social historians of medicine should be writing about the past expressly in order to illuminate the present; without closer engagement between past and present and between history and medicine, the history of medicine would become ‘an esoteric study’ and medical science would ‘continue to drift’.9 Although McKeown’s ‘sociological approach’ demonstrated substantial contextual awareness, his proposal to render social history the dedicated handmaiden of modern medicine was not universally accepted by social historians. In 1973, the Canadian scholar John F. Hutchinson, whose own research focused on the history of health and medicine in Russia and on the Red Cross, published a sharp rejection of McKeown’s position. While he accepted that much medical history was indeed sterile, largely because it constituted ‘mere antiquarianism’, Hutchinson insisted that McKeown’s central motivation for studying history, namely to ‘provide necessary information for reforming present evils’, was essentially ‘unhistorical’. No historian can escape his own present, nor is it desirable that he should. However, he must not allow his attempts to understand the past to be guided exclusively by the transient concerns of the present. If, for example, the social historian of medicine assumes that medicine means modern scientific medicine, he cannot help but write a tale of the gradual but inevitable triumph of truth over error. Such an approach will distort the past, and probably the present as well, as surely as did those written about the Reformation by nineteenth-century Whig historians.10

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By drawing an unfavourable analogy between McKeown’s vision of the social history of medicine and previous Whig histories, Hutchinson was attempting to expose what he regarded perhaps as McKeown’s fundamental error, namely his assumption that ‘medical history is somehow different from the rest of man’s history’. On the contrary, Hutchinson argued, historians of medicine were faced with much the same problems concerning sources, methods, and interpretations as other social historians: in all forms of historical enquiry, critical debates did not revolve around simplistic notions of how to extract ‘lessons from the past’, but around ‘the nature of historical perspective, the proper limits of generalization in history, and the objectivity or subjectivity of historical judgement’.11 Without recognizing the inherent similarities between social history and the history of medicine, McKeown was erecting ‘philosophical and methodological barriers which could separate social historians of medicine from those who should be their closest colleagues’.12 McKeown’s response to Hutchinson’s criticisms, published in the same issue of Medical History, was equally direct. In particular, he emphasized the manner in which historical research was able to ‘provide valuable perspective on some present-day medical problems’, such as the possible impact of health interventions on patterns of disease, most notably in developing countries, and his belief that some historical questions could only be satisfactorily answered by researchers with knowledge of present-day medicine. Dismissing Hutchinson’s overly narrow ‘scholastic definition of historical interests’, McKeown concluded that it can ‘hardly be to the advantage of historical studies to define outside their scope investigations of the past whose results can be relied on and are demonstrably useful’.13 There was, of course, a particular professional context to this acerbic historiographical dispute, one shaped by contemporary debates within both history and medicine. During the 1960s, a number of prominent historians had published polemical analyses of the nature and purpose of history. In 1969, for example, J. H. Plumb, Professor of Modern English History at the University of Cambridge, proposed a distinction between ‘the past’ and history. While the past comprised ‘a created ideology with a purpose, designed to control individuals, or motivate societies, or inspire classes’ and vulnerable to corruption, history constituted ‘an intellectual process’ intended not only to display ‘things as they really were’, but also to ‘formulate processes of social change which are acceptable on historical grounds and none other’.14 Compelling though Plumb’s rhetoric was, there were clearly problems with his prescription. As he himself admitted, similarities and analogies between the past and the present, and the inability of historians to free themselves completely from ‘either moral or political judgements’, served to undermine any crude distinction between the past and history; indeed, Plumb’s belief that ‘the future of history and historians is to cleanse the story of mankind from those deceiving visions of a purposeful past’ could itself be interpreted as precisely the kind of ideological pursuit that he was so keen to dismiss.15 It is evident, nevertheless, that Plumb had adroitly captured the key elements of a potent intradisciplinary divide between the relativism of E. H. Carr, according to which history was ‘an unending dialogue between the present and the past’,16 and G. R. Elton’s

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more traditional commitment to history as the search for objective truth, a truth that could necessarily only be discovered by historians. Although (or perhaps because) the epistemological basis of both positions was challenged during the 1980s by the linguistic focus of post-modernism, according to which historians essentially create their own narratives of, and meanings for, the past, this dispute about the nature and purpose of history continued to haunt the discipline, precipitating what some commentators have referred to as a crisis of confidence within the field and encouraging historians to defend the conceptual, methodological, and empirical validity of their work.17 In addition to revealing many of the disciplinary tensions evident within academic history at the time, the exchange between McKeown and Hutchinson also reflected competing political visions of medicine and social welfare in the decades following the Second World War. As Dorothy Porter has suggested, the SSHM was originally founded by a group of public health professionals and historians who were not only interested in the history of the public health movement, largely as a means of improving the education of health professionals, but also committed to ‘social medicine’.18 Shaped by James Lorimer Halliday’s formulation of psychosocial medicine and John Ryle’s notion of ‘social pathology’, social medicine in Britain offered an alternative to overly technical approaches to health and disease, one that emphasized the role of socioeconomic factors in disease causation and prevention.19 In North America, similar programmes of progressive socioeconomic reform and preventative health care were promoted by proponents of social psychiatry and endorsed by President J. F. Kennedy.20 Thomas McKeown’s inaugural address to the SSHM, as well as the Society’s early membership and its initial statement of aims, thus reflected a professional (albeit, arguably, a marginal) medical commitment to exploring and understanding the ‘relationship of medicine to society’ in order to improve both preventative and curative health care.21 From this clinical and public health perspective, the history of medicine constituted merely a subordinate tool of enquiry. During the 1970s, however, as membership of the Society expanded to include a wider range of disciplinary interests, its mission also shifted. Triggered partly by the election of Charles Webster as President of the SSHM in 1976, by the late 1970s the social history of medicine was regarded as ‘an independent scholarly pursuit, with its own methodologies and parameters’ and divorced from its earlier ‘vocational orientation toward policy and administration’.22 This is not to say that ‘relevance’ was no longer important to historians of medicine; rather, it was apparent that careful historical analysis revealed a ‘deeper kind of relevance’ generated not by drawing simple lessons from the past and applying them to present problems, which according to Hutchinson appeared to be McKeown’s sole intent, but by paying close attention to the social, political, and cultural contexts in which particular forms of medical knowledge and clinical practice were formulated and particular patterns of health and disease were experienced.23 In this way, the history of medicine came to be allied in academic terms not primarily with medicine and its professional and political concerns, but with the methods and approaches of social history. Closer alignment with social history led to the adoption of innovative methods within the history of medicine. As several prominent historians such as Arthur Marwick have

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commented, during the 1970s and 1980s it became fashionable to suggest that ‘all facets of human experience and activity are socially constructed, that is to say that there can be no totally objective science, history, literary scholarship, etc., all being influenced by the society in which they are created’.24 Although Marwick’s contention was largely directed at the dispute between Carr and Elton about the determinants of historical knowledge and the purpose of history, social construction became a key feature of the new social history of medicine as it emerged under the leadership of Webster and others. According to Ludmilla Jordanova, who, as a member of the SSHM executive committee, also played a key role in shaping the discipline during this period, social constructionism provided theoretical cohesion to the field, allowing scholars to conceptualize more clearly the relationship between medicine and society: It may be fruitful to think of social constructionism as delineating a space which the social history of medicine can occupy. By stressing the ways in which scientific and medical ideas and practices are shaped in a given context, it enjoins historians to conceptualize, explain and interpret the processes through which this happens. The old Whiggish history permitted no such spaces to exist.25

During the closing decades of the twentieth century, social constructionism provided the implicit, and occasionally explicit, methodological framework for much social history of medicine, at least in Britain, contributing to claims that the sub-discipline had finally ‘come of age’.26 As Jordanova and others have pointed out, however, such claims to maturity were perhaps themselves premature.27 Although academic focus on social construction served to bring together disparate approaches within the history of medicine and to draw historians of medicine closer to social and cultural history, scholars in the field not only remained divided by methods and sources but also continued to be plagued by disputes about the purpose of medical history and the nature of its relationship with both history and medicine. In some ways, persistent ambiguities stemmed from the diverse intellectual and political roots of social constructionism. According to Jordanova, the notion of social construction was informed by a number of adjacent developments during the 1960s and 1970s: the philosophy of science; the ‘revolt against Whiggish history’; the sociology of knowledge; the impact of anthropology; feminist critiques of medicine; growing preoccupations with how interests shaped knowledge; debates about the use of nature within scientific and medical discourses; and historical focus on specific localities.28 Although predominantly intellectual and historiographical, these developments were also openly political. Thus, even as they began to unite around a common commitment to exposing and analysing the contextual determinants of medical knowledge and practice and illness experience, some social historians of medicine were also engaged in (and divided by) a political venture to challenge the cultural hegemony of modern medicine and science, thereby perpetuating the rift that had been apparent in the exchange between McKeown and Hutchinson. At the dawn of the twenty-first century, these fault lines within the field deepened, rather than receded, as leading historians of medicine once again questioned the meaning and purpose of their discipline and its uneasy relation with its subject. However, in

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recent analyses, the traditional disciplinary orientation, evidenced by McKeown (the scientist) and Hutchinson (the historian), has strangely been reversed. In a provocative article published in 2001, in which he reviewed Cooter and Pickstone’s Medicine in the Twentieth Century, Paolo Palladino perhaps unexpectedly suggested that, despite their historical sophistication, contributors to Cooter and Pickstone’s volume ultimately failed either to recognize the uncertainties of their own discipline or to engage fully with the tensions between past, present, and future. By contrast, although they displayed ‘historiographical inadequacies’, the histories of medicine written by clinicians often realized precisely ‘what was at stake in telling a history, namely the future’.29 Palladino’s implied homage to McKeown, or at least his contention that social historians of medicine had in some ways lost their direction, was echoed by other scholars. According to Rhodri Hayward, not only had ‘old territorial disputes between clinicians and social historians’ resurfaced at recent American conferences, but widespread adherence to social constructionism had also alienated social and cultural historians of medicine from colleagues in epidemiology, demography, and economic history. Although Hayward adopted a more optimistic view of the field than Palladino, pointing to the potential for Charles Rosenberg’s notion of ‘framing’ or recent studies of ‘emergence’ to re-energize scholarship, he also recognized that historians of medicine faced a dilemma that was not likely to be resolved by mobilizing the traditional, relatively unstable, categories employed by social historians of medicine, such as ‘language, pathogens, identity or technology’. In an argument that acknowledged the value of both scientific and historical models in shaping the history of medicine, Hayward stressed the importance of pursuing a synthetic approach that constructively managed the catholicity that he felt was ‘stultifying the field’.30 In 2007, Roger Cooter launched a more caustic challenge to the discipline, one reminiscent of McKeown’s impassioned plea many years earlier for a more fertile history of medicine. Although the history of medicine was thriving in institutional terms, Cooter argued, politically and intellectually it was ‘sterile’, having ‘lost its capacity seriously to engage’.31 As the social history of medicine threatened to collapse under the weight of the assault from Foucault and post-modernism, it was no longer viable to reinvigorate the field simply by ‘historiographically tweaking the sub-discipline in accord with contemporary political, cultural and economic conditions, or merely through a change of spots that re-brands it “the cultural history of medicine” ’. The conceptual and methodological problems ran deeper than disciplinary cosmetics: established categories of analysis had been undermined and the initial political motives of social history of medicine, evident in McKeown’s presidential address, had been abandoned. The solution, for Cooter, lay in a more critical historical engagement with ‘the re-configurations of medicine and the body’ that have been fashioned by modern biomedicine: new forms of knowledge demand new ways of thinking not only about the present and the future, but also about the past.32 Cooter’s diagnosis of the intellectual, or perhaps emotional, void at the heart of the history of medicine and his prescription for improved health have not been universally accepted by his colleagues. Although Jonathan Toms has acknowledged that Cooter’s

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analysis offers challenging opportunities to reflect on the field, he remains unconvinced that the promotion of ‘medico-centric historians, armed with a theory of power/knowledge, and directing their “expertise” to the biosciences and biopolitics’, effectively resolves the ‘postmodern predicament’, preferring instead to validate established scholarship that has, in particular, focused effectively on the ‘politics of professions and professional selfinterest’.33 This recent dispute about the methods and meanings of the history of medicine carries echoes of the debate between McKeown and Hutchinson in the 1970s; now, as then, the history of medicine occupies an ambiguous position between the past and the present, between medicine and history, between competing disciplinary claims to power and authority. As I shall suggest in the next section, one of the most critical and persistent conceptual issues within these disputes, and one that also animates the broader field of history, is the notion of relevance.

The relevance of history In 1997, in his ‘defence of history’, Richard J. Evans, whose publications include a monumental study of cholera in late-nineteenth-century Hamburg, warned colleagues about the dangers of ‘drawing up the disciplinary drawbridge’ between contrasting historiographical approaches. Arguing that historians had already benefited profusely from the methods and insights of the social sciences and echoing Carr’s earlier preoccupations with the complex, but necessary, exchange between past and present, Evans suggested that the questions raised by alternative modes of historical analysis not only encouraged historians to constructively ‘re-examine the theory and practice of their own discipline’, but also carried broader social implications: In this sense, the problem of how historians approach the acquisition of knowledge about the past, and whether they can ever wholly succeed in this enterprise, symbolizes the much bigger problem of how far society can ever attain the kind of objective certainty about the great issues of our time that can serve as a reliable basis for taking the vital decisions for our future in the twenty-first century.34

Evans’s appeal to historians to adopt broader methodological horizons and to reflect on their own historiographical preferences was thus animated by a belief that debates about historical method, as well as the outcomes of historical analysis, carried potential relevance for current societies, a belief that has been reiterated regularly in debates about the public value of the humanities.35 Within the history of medicine, concerns about relevance have been particularly prominent, driven in part by the discipline’s historical roots in social medicine, in part by the diverse and contrasting methodologies already evident in the field, and in part, in Britain at least, by funding opportunities. Since the middle decades of the twentieth century, much British and some overseas history of medicine has been funded by the Wellcome Trust. The impact of generous financial support is clear: over recent decades the history of medicine has become effectively

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embedded in the institutional fabric of many British universities, contributing to the vibrancy and scholarly strengths of the discipline. However, as a charitable organization committed to improving human and animal health by investing in scientific and clinical research, the Wellcome Trust has also, not surprisingly, promoted closer scholarly attention to the applicability, or relevance, of research in history and the humanities, thereby becoming a ‘key vector for the historical message about health and science’.36 As contributions to this Handbook make clear, the relevance or instrumental value of medical history to modern societies operates at a number of levels, relating not only to its analytical attention to context, but also to its ability to deepen our understanding of current health policies and practice and its capacity to facilitate the elucidation of particular epidemiological and demographic questions. In the first instance, the value of history stems from its focus on the contextual determinants of medical knowledge and practice across both time and space. Without needing to resort to the contentious practice of extrapolating directly from the past to the present, the historical method itself raises important questions about the roles of social, biological, political, economic, and cultural factors in shaping patterns and experiences of health and disease and in defining hegemonic approaches to diagnosis and treatment. A fully contextual, constructivist history of medicine thus promises to explain how and why clinical practices changed or remained relatively constant across time, for example, or how and why particular formulations of health and disease became prominent at particular historical moments. Understanding the complex sequential determinants of medical knowledge and patient experiences in the past not only deepens the historical literacy of modern societies, but also offers a constructive analytical model for evaluating and confronting current knowledge claims. The intellectual value of historical studies of this nature is evident. For example, in his contribution to this volume, Philip van der Eijk carefully dispels the myth of a singular Graeco-Roman medicine, highlighting by contrast the plurality of medical understandings, clinical approaches, and patient experiences in the ancient world. The diversity of accounts of mental disease in Greek medical literature, for example, and the degree of conflict and disagreement between physicians should alert us to the dangers of assuming or asserting philosophical concord and therapeutic conformity.37 Similarly, by focusing on shifting clinical models of the psyche since the late eighteenth century, Rhodri Hayward challenges modern notions that the mind is ‘a substantial entity with a consistent set of characteristics’, highlighting instead how mental phenomena have ‘been repeatedly reconfigured around different agendas and using different imaginative material’.38 The fluid and contested nature of seemingly concrete medical and social categories is also exposed by Susannah Ottaway’s discussion of how the relationship between health and old age has varied across time and cultures, shaped not only by fundamental shifts in lifespan, but also by striking changes in social expectations and experiences.39 In these and other contributions to the Handbook, historians of medicine thus offer critical reflections on the validity and stability of many historical assumptions about both the past and present.

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There is a second, perhaps more contentious and potentially more restrictive, way in which history can be regarded as relevant to modern societies. As Virginia Berridge and Philip Strong have argued in the context of historical studies of AIDS, many supposedly innovative health policies often ‘possess deep roots in the past’, roots that historians of medicine are ideally placed to expose: ‘Historians, more than most other social scientists, have the capacity to locate policy change in past practice, to seek out the antecedents and tendencies which feed into present policy developments.’40 Of course, as Virginia Berridge makes clear in her contribution to this volume and elsewhere,41 there are specific challenges raised by writing contemporary history, most notably the risk of being drawn into teleological accounts of progress and development. Attempting to make historical research relevant in this way also unduly prioritizes modern or recent history at the expense of more distant studies. However, it is clear that in a world where public engagement and impact are increasingly regarded as pivotal aspirations for academic historians, and in some cases a principal criterion for continued funding, carefully contextualized studies of recent policies and practices offer opportunities for historians to inform debates about current dilemmas. As George Rosen insisted many years ago, the pursuit of what some scholars have termed ‘critical applied history’ or ‘practical historicism’42 of this nature also carries benefits for medical education, exposing students, as well as doctors, to the complex historical and contextual determinants of their own knowledge and practice.43 The potential research and educational impact of policy-relevant, but not policy-led, history is demonstrated by the History and Policy network, established in 2002. As Simon Szreter has suggested in his discussion of the benefits of alerting policy-makers and practitioners to previous patterns of welfare reform, for example, one of the values of history ‘in a liberal democracy can be to inform the deliberate process of policymaking’ by providing key ‘intellectual resources’. By recognizing the manner in which the past operates as one of the contextual determinants of the present, history ‘provides a way of thinking about society and its component parts, about the messy, conflicted and negotiated process of change and about the differences between perspectives of different agents, a disposition which potentially can assist in the field of policy formation and implementation’.44 The potential for historians of medicine to provide both perspective and context to ongoing policy debates is evident in several chapters in this Handbook. In his provocative discussion of the history of environmental health reform, for example, Christopher Sellers emphasizes the impact of both non-medical specialties (including entomology, engineering, and ecology) and lay concepts and categories on health intervention. In the process, he effectively reveals the manner in which modern medical knowledge and practice have been, and continue to be, shaped by the economic and political interests of competing agents. Equally, Martin Gorsky’s account of the political economy of welfare explores how different national health systems emerged within, and responded to, particular demographic, financial, and technological changes. In the process, Gorsky not only contributes to a burgeoning interest in comparative, transnational histories of medicine, but also exposes the manner in which

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both the language and the mechanisms of welfare reform are neither value-neutral nor transparent.45 Gorsky’s coda, in which he reflects on the health impact of alternative welfare systems, suggests an even more directly pragmatic role for the history of medicine. In recent decades, historical studies have contributed substantially to our understanding of the epidemiological transition, that is, to our appreciation of the complex patterns of morbidity, mortality, and fertility that have led to dramatic increases in life expectancy amongst modern Western populations.46 In part, this area of historical research was catalysed by Thomas McKeown’s programmatic studies of the decline of infectious diseases and falling mortality rates in Britain since the mid-nineteenth century, and perhaps also by his provocative challenge to medical historians in his presidential address to the SSHM in 1970.47 Although the place of historical demography within the history of medicine has arguably been usurped by more fashionable social and cultural histories, a number of scholars have continued to analyse historical patterns of morbidity and mortality in order to deepen our knowledge of the burden and experiences of disease in the past and to evaluate the impact of public health measures and clinical interventions. Recently, Robert Woods, one of the leading contributors to quantitative historical studies of health and mortality, has argued for even greater scholarly attention to epidemiological and demographic questions of this nature. Although he acknowledges the multiple obstacles to developing an ‘evidence-based medical history’ that attempts to establish the results of medical intervention, he suggests nevertheless that historians of medicine should engage more fully with current debates about the effectiveness of public health measures and modern treatments: ‘Health impact assessment (HIA) needs to occupy a central position in medical history, just as it does in contemporary medical practice.’48 Woods’s impassioned plea to resurrect the interdisciplinary agenda set by McKeown over forty years ago, or to recognize and accept the dual heritage of medical history, is inspiring and disturbing in equal measure. At one level, it offers historians of medicine a distinct and welcome point of contact with doctors and policy-makers and indeed with the public, thereby promoting the heuristic and pragmatic value of history and the wider medical humanities. At another level, it requires historians to suspend, at least momentarily, some of the rigorous cynicism that has underpinned many exemplary studies of the manner in which medical knowledge and practice have been constructed in the past. Perhaps surprisingly, given the widespread appeal of social constructivist approaches in recent decades, contributors to this Handbook have been eager to mine (or at least expose) what might prove to be a relatively rich seam of uncertainty. Without abandoning their attention to historical contingencies and the contested nature of both practice and policy, the chapters by Sanjoy Bhattacharya, Vivienne Lo and Michael Stanley-Baker, Anne-Emanuelle Birn, and Christopher Hamlin, for example, collectively point to the policy-relevance of global histories of public health and disease eradication strategies, to the productive, if contentious, interplay between history and practice, and to the opportunities now available for history to play ‘less of an oppositional, and more of a synthetic (if still critical), role’ in debates about measuring and improving health.49

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Conclusion: themes and directions At the heart of this Handbook lie two related convictions. In the first instance, this volume is informed by a strong belief that the history of medicine is relevant both to the broader field of social history and to current disputes about health and medicine. Although the historical method is concerned primarily with the past, that is with opening up new ways of understanding how health and disease have been experienced and managed in past times, the scope and meanings of medical history are also overtly shaped by, and contribute to, present debates. From this perspective, history not only offers a constructive point of articulation between past and present, but also reveals (or, perhaps more critically, exemplifies) the manner in which the past continues to impact on the present. Expressed in relatively abstract, mathematical terms, the past and present to some extent exist simultaneously as well as sequentially; put more concretely, as William Faulkner suggests in the epigram to this introduction, the ‘past is never dead. It’s not even past.’50 Secondly, this Handbook is predicated on a belief that, in addition to operating at the interface between past and present, the history of medicine can serve as a point of articulation between its parent disciplines. Conceived and nurtured by both medicine and history, the history of medicine has, perhaps since its birth, suffered from an identity crisis generated by its indeterminate disciplinary status. On occasions, professional uncertainty and the indistinct boundaries of the discipline have engendered overt hostility between historians and doctors about the nature and purpose of medical history.51 However, while a sense of ambiguity about the subject’s intellectual and professional heritage has periodically unsettled historians of medicine, the discipline’s dual citizenship carries distinct advantages. As the scholarship contained within this Handbook demonstrates, the variety of approaches and interests subsumed by the history of medicine multiplies the potential audience, maximizes the possibility of impact, and stimulates necessary reflection and debate about sources, methods, interpretations, and relevance. In this context, rather than trying to identify and impose an ideal method for the history of medicine, this Handbook acknowledges and celebrates the ‘remarkable diversity’ of methodological approaches and thematic concerns that have animated historians of medicine over the course of the past half-century or so, while at the same time offering suggestions for future scholarship.52 The Handbook is divided into three sections. The first section focuses on the history of medicine at different times, exploring historical and historiographical issues relating to health and medicine in the ancient world, in the medieval and early modern periods, during the Enlightenment and industrial modernity, and in the recent past. Although these chronological divisions appear relatively familiar, contributors have been encouraged not only to challenge historiographical conventions by problematizing the manner in which periods have been defined and mobilized for the purposes of historical analysis, but also to consider the value of longue durée approaches to history. One of the major

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concerns to emerge from these opening chapters is the pressing need for more critical, and carefully contextualized, editions of ancient and medieval texts. In addition, although contributions to this opening section focus predominantly on Western traditions, they also highlight the importance of intellectual and geographical breadth in shaping historical narratives. The second section of the Handbook explores the evolution of medical traditions, as well as historiographical developments, in different regions of the world. Opening with a provocative study of the importance of transnational comparative histories of medicine and disease and of the potential value of global history,53 one of the aims of this section is to counter the dominance of Western-focused histories of medicine and to foreground and energize scholarship in geographical areas that have been relatively poorly covered by recent historiography. Thus, in addition to chapters on Western Europe and North America, this section includes historical studies of Eastern Europe, Latin America, South Asia, sub-Saharan Africa, and Australasia, as well as reflections on Chinese and Islamic medical traditions. As several of the contributors make clear, the history of medicine in these regions should not be written from a Western perspective, concerned only with those diseases, cultural preoccupations, professional practices, and institutions recognized by the West. Instead, they should explore indigenous medical traditions, and the diverse range of social and cultural factors that have shaped them, on their own terms. The final section explores the past largely in thematic terms. The topics are not intended to be comprehensive. As well as being dictated partly by the availability of scholars, they have also been chosen to display the rich variety of interlocking themes and methods that has come to characterize the history of medicine in recent decades and to identify novel areas of enquiry, undeveloped methods, and original sources for future scholars to pursue with more vigour. While individual contributions speak clearly and separately for themselves, some common themes do appear to haunt them: in particular, these thematic chapters offer a persuasive case for extending and challenging the traditional boundaries of medical history, geographically, chronologically, conceptually, and methodologically. In doing so, they collectively establish the history of medicine as a vibrant and meaningful endeavour that has much to contribute to ongoing debates about the past, present, and future of both history and medicine.

Notes 1. W. F. Bynum and Roy Porter (eds), Companion Encyclopedia of the History of Medicine (London/New York: Routledge, 1992). 2. Roy Porter and W. F. Bynum, ‘The Art and Science of Medicine’, in Bynum and Porter (eds), Companion Encyclopedia, 3–11. 3. For examples of broader studies, see: Lawrence I. Conrad, Michael Neve, Vivian Nutton, Roy Porter, and Andrew Wear, The Western Medical Tradition: 800 BC to AD 1800 (Cambridge: Cambridge University Press, 1995); Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present (London: HarperCollins, 1997); Jacalyn Duffin, History of Medicine: A Scandalously Short

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4. 5.

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

20.

21. 22. 23. 24. 25. 26. 27.

28.

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Introduction (Toronto: University of Toronto Press, 1999); John Pickstone, Ways of Knowing: A New History of Science, Technology and Medicine (Manchester: Manchester University Press, 2000); John Burnham, What is Medical History? (Cambridge: Polity Press, 2005); W. F. Bynum, Anne Hardy, Stephen Jacyna, Christopher Lawrence, and E. M. Tansey, The Western Medical Tradition 1800–2000 (Cambridge: Cambridge University Press, 2006). Roger Cooter and John Pickstone, ‘Introduction’, in eidem (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000), xiii–xix. Frank Huisman and John Harley Warner, ‘Medical histories’, in Frank Huisman and John Harley Warner (eds), Locating Medical History: The Stories and Their Meanings (Baltimore: Johns Hopkins University Press, 2004), 1–30. Dorothy Porter, ‘The Mission of Social History of Medicine: An Historical Overview’, Social History of Medicine, 8 (1995), 345–59. Huisman and Warner, ‘Medical Histories’, 11. Thomas McKeown, ‘A Sociological Approach to the History of Medicine’, Medical History, 14 (1970), 342–51. Ibid. 351. John F. Hutchinson, ‘Historical Method and the Social History of Medicine’, Medical History, 17 (1973), 423–8. Ibid. 424. Ibid. 427. ‘Dr. Thomas McKeown Replied to Dr. Hutchinson’s Comments as Follows’, Medical History, 17 (1973), 428–31. J. H. Plumb, The Death of the Past (London: Macmillan, 1969), 11–17. Ibid. 16–17. E. H. Carr, What is History? (London: Macmillan, 1961), 24. Richard J. Evans, In Defence of History (London: Granta Books, 1997), 3–9. Porter, ‘The Mission of Social History of Medicine’. James L. Halliday, Psychosocial Medicine: A Study of the Sick Society (London: William Heinemann, 1949); Dorothy Porter, ‘Changing Disciplines: John Ryle and the Making of Social Medicine in Britain in the 1940s’, History of Science, 30 (1992), 137–64. George Rosen, ‘Social Stress and Mental Disease from the Eighteenth Century to the Present: Some Origins of Social Psychiatry’, Millbank Memorial Fund Quarterly, 37 (1959), 5–32; Matthew Smith, ‘Psychiatry Limited: Hyperactivity and the Evolution of American Psychiatry, 1957–1980’, Social History of Medicine, 21 (2008), 541–59. Quoted in Porter, ‘The Mission of Social History of Medicine’, 346. Ibid. 352–3. The thrust of Webster’s presidential address is quoted in ibid. 351. Arthur Marwick, The Nature of History, 3rd edn (Basingstoke: Macmillan, 1989), 21. Ludmilla Jordanova, ‘The Social Construction of Medical Knowledge’, Social History of Medicine, 8 (1995), 361–81. Andrew Wear (ed.), Medicine in Society (Cambridge: Cambridge University Press, 1992), 1. Ludmilla Jordanova, ‘Has the Social History of Medicine Come of Age?’, The Historical Journal, 36 (1993), 437–49. See also David Harley, ‘Rhetoric and the Social Construction of Sickness and Healing’, Social History of Medicine, 12 (1999), 407–35. Jordanova, ‘The Social Construction of Medical Knowledge’.

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29. Paolo Palladino, ‘Medicine Yesterday, Today, and Tomorrow’, Social History of Medicine, 14 (2001), 539–51. 30. Rhodri Hayward, ‘Review Article: “Much Exaggerated”: The End of the History of Medicine’, Journal of Contemporary History, 40 (2005), 167–78. 31. Roger Cooter, ‘After Death/After-“Life”: The Social History of Medicine in Postpostmodernity’, Social History of Medicine, 20 (2007), 441–64. 32. Ibid. 444–5, 455–7. 33. Jonathan Toms, ‘So What? A Reply to Roger Cooter’s “After Death/After-‘Life’: The Social History of Medicine in Post-Postmodernity” ’, Social History of Medicine, 22 (2009), 609–15. 34. Evans, In Defence of History, 9. 35. For a recent expression of this position, see British Academy, Past Present and Future: The Public Value of the Humanities and Social Sciences (London: British Academy, 2010). 36. Virginia Berridge, ‘History Matters? History’s Role in Health Policy Making’, Medical History, 52 (2008), 311–26. 37. Philip van der Eijk, ‘Medicine and Health in the Graeco-Roman World’, Chapter 2 in this volume. 38. Rhodri Hayward, ‘Medicine and the Mind’, Chapter 29 in this volume. 39. Susannah Ottaway, ‘Medicine and Old Age’, Chapter 19 in this volume. 40. Virginia Berridge and Philip Strong, ‘AIDS and the Relevance of History’, Social History of Medicine, 4 (1991), 129–38. 41. Virginia Berridge, Marketing Health: Smoking and the Discourse of Public Health in Britain, 1945–2000 (Oxford: Oxford University Press, 2007); eadem, ‘History matters?’. 42. John Tosh, Why History Matters (London: Palgrave Macmillan, 2008), cited in Simon Szreter, ‘History, Policy and the Social History of Medicine’, Social History of Medicine, 22 (2009), 235–44. 43. George Rosen, ‘The Place of History in Medical Education’, Bulletin of the History of Medicine, 22 (1948), 594–629; Brian Dolan, ‘History, Medical Humanities and Medical Education’, Social History of Medicine, 23 (2010), 393–405. 44. Szreter, ‘History, Policy and the Social History of Medicine’, 240. 45. Christopher Sellers, ‘Health, Work, and Environment: A Hippocratic Turn in Medical History’, Chapter 25 and Martin Gorsky, ‘The Political Economy of Health Care in the Nineteenth and Twentieth Centuries’, Chapter 24, both in this volume. 46. Simon Szreter, ‘The Importance of Social Intervention in Britain’s Mortality Decline c.1850–1914: A Re-interpretation of the Role of Public Health’, Social History of Medicine, 1 (1988), 1–37; Richard M. Smith, ‘Demography and Medicine’, in Bynum and Porter (eds), Companion Encyclopaedia of the History of Medicine, 1663–92; Simon Szreter, Fertility, Class and Gender in Britain, 1860–1940 (Cambridge: Cambridge University Press, 1996); Andrew Cliff, Peter Haggett, and Matthew Smallman-Raynor, Deciphering Global Epidemics: Analytical Approaches to the Disease Records of World Cities (Cambridge: Cambridge University Press, 1998); James C. Riley, Rising Life Expectancy: A Global History (Cambridge: Cambridge University Press, 2001). 47. Thomas McKeown, R. G. Record, and R. D. Turner, ‘An Interpretation of the Decline of Mortality in England and Wales during the Twentieth Century’, Population Studies, 29 (1975), 391–422: Thomas McKeown, The Modern Rise of Population (London: Edward Arnold, 1976); idem, ‘Fertility, Mortality and Causes of Death: An Examination of Issues Related to the Modern Rise of Population’, Population Studies, 32 (1978), 535–42.

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48. Robert Woods, ‘Medical and Demographic History: Inseparable?’, Social History of Medicine, 20 (2007), 483–503. 49. See Christopher Hamlin, ‘Public Health’, Chapter 23; Sanjoy Bhattacharya, ‘Global and Local Histories of Medicine: Interpretative Challenges and Future Possibilities’, Chapter 8; and Vivienne Lo and Michael Stanley-Baker, ‘Chinese Medicine’, Chapter 9, all in this volume. 50. William Faulkner, Requiem for a Nun (London: Chatto and Windus, 1953), 85. 51. Dolan, ‘History, Medical Humanities and Medical Education’. 52. Huisman and Warner, ‘Medical Histories’, 3; Mark Jackson, ‘Review Article: Disease and Diversity in History’, Social History of Medicine, 15 (2002), 323–40. 53. Ilana Löwy, ‘The Social History of Medicine: Beyond the Local’, Social History of Medicine, 20 (2007), 465–81.

Select Bibliography Berridge, Virginia, ‘History Matters? History’s Role in Health Policy Making’, Medical History, 52 (2008), 311–26. Bynum, W. F., and Roy Porter (eds), Companion Encyclopedia of the History of Medicine (London/New York: Routledge, 1992). Cooter, Roger, ‘After Death/After-“Life”: The Social History of Medicine in Post-Postmodernity’, Social History of Medicine, 20 (2007), 441–64. —— , and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000). Evans, Richard J., In Defence of History (London: Granta Books, 1997). Huisman, Frank, and John Harley Warner (eds), Locating Medical History: The Stories and Their Meanings (Baltimore: Johns Hopkins University Press, 2004). Hutchinson, John F., ‘Historical Method and the Social History of Medicine’, Medical History, 17 (1973), 423–8. Jordanova, Ludmilla, ‘The Social Construction of Medical Knowledge’, Social History of Medicine, 8 (1995), 361–81. McKeown, Thomas, ‘A Sociological Approach to the History of Medicine’, Medical History, 14 (1970), 342–51. Porter, Dorothy, ‘The Mission of Social History of Medicine: An Historical Overview’, Social History of Medicine, 8 (1995), 345–59. Plumb, J. H., The Death of the Past (London: Macmillan, 1969). Woods, Robert, ‘Medical and Demographic History: Inseparable?’, Social History of Medicine, 20 (2007), 483–503.

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PER IODS

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chapter 2

m edici n e a n d h e a lt h i n t h e gr a eco -rom a n wor ld p hilip van der e ijk

Graeco-Roman medicine has always had a secure place in general accounts of the history of medicine, usually at the beginning. This reflected not only its chronological position but also the belief that ancient medicine was somehow the foundation or ‘cradle’ of the Western medical tradition, with Hippocrates, the ‘Father of Medicine’, as its great hero and Galen as ‘the Prince of Physicians’ securing its legacy and putting his own stamp on it. From this perspective, Graeco-Roman medicine was ‘classical’ not only in the chronological but also in the paradigmatic sense of the word. The Hippocratic Oath with its high moral standards was believed to have laid the foundation for medical ethics;1 the Hippocratic Epidemics had provided the model for the clinical case-history, based on meticulous recording of empirical observations; the Hippocratic work On the Sacred Disease had advanced rational, natural explanation of phenomena hitherto ascribed to the divine and the supernatural; and Galen’s experiments in dissection and pharmacology, along with his systematic theory of the human body and his insistence on logical rigour, had established an ideal methodological combination of empirical observation and sound reasoning. Not surprisingly, the works attributed to Hippocrates and Galen remained influential in medical theory, teaching, and practice until well into the nineteenth century (and in some areas even beyond that); and it is no coincidence that the standard editions of these works, still in use in today’s scholarship, were produced in that time frame, and by doctors: from 1839 onwards, the French physician Emile Littré published the ten volumes Oeuvres complètes d’Hippocrate, while a little earlier in the nineteenth century the German doctor Karl Gottlob Kühn put together the twenty-two-volume Opera omnia of Galen.2 One of the reasons this perception was so persistent was that the subject of GraecoRoman medicine used to be the domain of two groups of students, each of whom had their own reasons for cherishing this idealized picture. On the one hand, there were

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classicists, for whom the emergence of Greek medicine was part of the Greek ‘miracle’— the sudden rise of Greek civilization and of rational and ethical thinking in the fifth century bce—and for whom documents such as the Hippocratic writings provided powerful support to the justification of the study of classical civilization for its relevance to today’s world. On the other hand, there were physicians, often retired, with an excellent training in the classical languages (dating back to their school days), who believed that their medical practice stood in a long and venerable tradition, whose pedigree could be traced back to the days of the ancient Greeks.3 Over the past few decades, however, there have been a number of developments that have made the place of Graeco-Roman medicine in surveys of the history of medicine less straightforward. These developments constitute the principal focus of this chapter.

Changing approaches to the historiography of ancient medicine It is clear that globalization, the advent of alternative medicine, and the pluralism of medical traditions in today’s medical world, have questioned the Hellenocentrism of earlier historiographical approaches and cast doubt on the privileged position that Greek medicine used to enjoy in the attention of many generations of students and the wider public.4 After all, it is argued, why should a course on the history of medicine begin with ancient Greece when, compared with other ‘traditional’ systems such as Ayurvedic or Chinese medicine, Graeco-Roman medicine is probably one of the least influential— or at any rate least manifestly influential—when it comes to today’s therapeutic practice? Developments within medical history as an academic discipline, especially the rise of social and cultural approaches to the history of medicine, have also made students of Graeco-Roman medicine aware of the benefits that contextualization can bring to the subject.5 This has not been straightforward. The main body of evidence, Greek and Latin medical texts (sometimes surviving in Arabic and Syriac translations only), are technical and their study is extremely difficult and time-consuming, requiring highly specialized skills. Most of these texts survive only in medieval manuscripts, representing stages of transmission many centuries after they were written, and in the process of manual copying, changes and errors crept in. The study of this process of textual transmission, involving painstaking collection, deciphering and comparison of different textual versions, and the constitution of ‘the’ text (which is often only an approximate hypothesis as to what the author is most likely to have written) is a field in its own right, one that has usually left little room for contextual, social, or cultural perspectives. As a result, the professional study of Graeco-Roman medicine was long dominated by what has sometimes been called ‘the philological paradigm’, a scholarly discourse preoccupied with discussions about manuscript traditions, textual variants, different versions of the same text, sources, influences, ‘master–pupil relations’, textual layers, and the semantics of

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particular terms. With some exceptions, this paradigm did not encourage scholars to look beyond the texts and it created the impression of the history of ancient medicine as a ‘world in words’, a textual structure and an intertextual network in which authors of medical texts read and responded to one another, adopted each other’s ideas, and wrote treatises and commentaries on each other’s works, without much consideration of the world in which these texts may have functioned or the world they possibly reflected.6 In addition, this approach rendered the subject inaccessible to the increasing numbers of scholars and students without adequate knowledge of Latin or Greek or lacking the skills even to interpret the results of sometimes overly complicated textual, philological scholarship. This has long posed an obstacle to dialogue between students of ancient medicine and historians of medicine in later times or in non-Western parts of the world. This divide between students of classical (and to some extent medieval) medicine and those concerned with later periods (or non-Western parts of the world) has narrowed considerably over the past few decades, but there is still some way to go and the connection is not always easily made. Apart from issues of accessibility, sources for the GraecoRoman period are limited and fragmentary, and often permit only partial, or largely hypothetical, answers to the type of questions raised by historians of later times, relating to social demographic issues, for example, or to questions about the patient’s perspective, for which there is very little evidence. Furthermore, there is sometimes a sense of anachronism or even amateurism when comparisons are made between different time frames or when terms such as ‘healthcare system’ or ‘medicalization’ are applied to pre-1700 periods. Nevertheless, there have been a number of successful attempts at bridging the gap and at opening up the subject to a wider group of scholars: virtually all editions of Greek or Latin medical texts are now accompanied by translations in a modern language, and likewise monographs and journal articles are often presented in ways that enable engagement from non-classical readers. Moreover, a number of scholars have been trying to relate the study of Graeco-Roman medicine more closely to developments in later periods,7 or to compare them with the development of medicine and science in different parts of the world.8 There are also encouraging signs of collaboration between disciplines, including bio-archaeology and the medical sciences, and although the advent of social and cultural approaches to medical history initially caused medics to be sidelined, it is now increasingly (re-)appreciated that they do have a contribution to make.9 A further recent, related, development is that what was long believed to make Greek medicine so unique and distinctive, namely its ‘rationality’,10 is no longer privileged as its most interesting aspect or viewed as the most rewarding reason for studying it. The desire to hail the emergence of Greek ‘rational’ medicine as the triumph of reason over superstition is less great now than it was in the mid-twentieth century, when it was clearly motivated by progressivist paradigms in the historiography of medicine and, more widely, by secularism in Western society. By contrast, there is greater appreciation now of the ‘irrational’ sides of Greek medicine, not only of the role of religion, healing cults, and magic and their continuing importance despite the advent of ‘secular’ medicine,11 but also of the profoundly religious nature of much of Greek ‘science’.12 Thus there is Galen’s belief in a divine, providential purpose underlying the design of the

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human body, which in turn is a continuation of similar ideas in Plato and Aristotle, or Herophilus’ view that drugs are ‘the hands of the gods’, indicating that even if Greek doctors seem not to have allowed the gods or the divine to play much of an explicit role in their theories and practices, this should not be interpreted as evidence of diminishing religiosity, let alone atheism. There has further been an increasing awareness of the speculative and hardly rationally justifiable components of much Greek medical theory, such as the role of number symbolism in Greek embryology and in the doctrine of critical days, or of the uncritical assumptions—rarely backed up by unequivocal empirical evidence—underlying much of Greek physiological thinking (such as the theory of humours). Furthermore, comparisons with Babylonian and Egyptian medicine have shown that Greek medicine had more in common with its Near Eastern neighbours, often dismissed as ‘irrational’ and ‘superstitious’, than scholarship used to assume.13 And finally, unsurprisingly in the age of post-modernism, scholarship has become more sensitive to what may be called the plurality of rationalities and alternative modes of thinking in the Graeco-Roman world: modes of reasoning whose logical legitimacy is not immediately apparent or uncontroversial, such as the role of metaphor, analogy, and other ‘correspondence’ relationships in Greek scientific thought, or indeed the fanciful nature of whole sub-disciplines, such as astrological medicine, alchemy, and particular aspects of pharmacology. These developments are related to the wider question of what medical history is about, that is, whether it is concerned with the history of medical ‘science’—or, if one wishes to avoid that word, its pre-1900 equivalents of ‘intellectual medical history’, ‘history of medical thought’, ‘history of medical ideas’, or ‘history of medical inquiry’—or much more broadly with what could be described as the history of human responses to disease and to related phenomena such as pain, old age, and death.14 The ‘intellectualist’ perspective on the history of medicine long dominated the discourse and led to an almost exclusive focus on ideas, on the philosophical and theoretical aspects of medicine, and on those respects in which the medicine of earlier times was believed to be a precursor of medical science today. In the old days, it led to accounts of medical history that laid emphasis on successes, discoveries, advances, and progress but ignored or marginalized the irrational, the superstitious, the failures, and the setbacks (or what were perceived as such). In the study of ancient medicine, this interest was initially fuelled by the desire to regard Greek medicine as the foundation and starting point of a teleological development that found its culmination in the biomedicine we are familiar with today. More recently, the intellectualist approach to the study of Greek medicine received a further boost—though based on somewhat different premises—from the study of ancient philosophy,15 where increasing appreciation has been given to the philosophical interests of medical writers such as Galen, Diocles, and Erasistratus, and the contribution made by these writers to the articulation of philosophical ideas, in particular about the methodology, epistemology, and ethics of medicine and specific areas such as the mind– body interface. Yet within this intellectualist discourse changes have taken place as well, for while in earlier historiography the ‘philosophical’ and ‘theoretical’ aspects of Greek

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medicine were sometimes presented as having posed ‘epistemic obstacles’ to the development of an ‘empirical’ medical science, the prevailing view now is that such distinctions cannot really be made and that the theoretical and empirical were inextricably interwoven. More generally, scholarly appreciation of the close interaction between medicine and philosophy in the ancient world—itself a long-established idea—has more recently led to a blurring of the dividing lines between these ‘disciplines’. This reflects more general trends in intellectual history, history of ideas, and, more broadly, the social and institutional history of science and the sociology of scientific knowledge, in which ideas, intellectual processes, and indeed whole intellectual ‘disciplines’ are contextualized and historicized and in which the emergence, spread, and establishment of specific ideas is explained, at least partly, by reference to social and cultural factors. Yet medical history now has a much broader brief, encompassing the study of illness and human suffering in the past, the history of disease, and the various ways in which individuals and social groups have responded to disease. Such ‘responses’ can be reflected in beliefs and theories about sickness and the body and in corresponding healing practices. Yet, as medical anthropology, the sociology of health care, and the comparative history of medicine have shown, such beliefs and practices can take a number of different forms, with different social, cultural, and institutional ramifications; and what we have come to refer to as ‘medicine’,16 or indeed medical ‘science’ (or attempts at attaining this), is only one among a variety of such responses—a variety that already begins at the level of personal experience (what individuals or groups in a particular society experience as pain or illness or disability or discomfort may differ from one case to another), and which is even greater at the level of how people understand, conceptualize, name, label, categorize, and systematize experiences of disease, and again greater when it comes to acting on such experiences, which may range from treating, curing, combating, conjuring and ritualizing pathological phenomena to accommodating, accepting, rationalizing, resigning to them or even welcoming them within one’s ‘world view’. These different reactions may take varying social and cultural forms, of which institutionalized medical care that we are familiar with in the Western medical tradition is only one among others, such as temple medicine, healing cults, family or clan practices, and religious associations. This renewed scholarly awareness of the plurality of attitudes to disease is reflected in the language of many twenty-first-century medical historians, who have become increasingly cautious and now prefer to speak, in relation to the more distant medical past, of ‘healers’ and ‘therapeutic intervention’ rather than ‘doctors’ or ‘medicine’ because of the latter’s implicit Western biomedical bias. It has also had major implications for the study of health and disease in the Graeco-Roman world, encouraging classicists and historians of ancient medicine to rethink both the reasons and the methodology for studying Greek and Roman medicine. Greek medicine is no longer studied primarily for its being part of le miracle grec, nor even exclusively because of its formative influence on ‘the Western medical tradition’—however important that latter point continues to be—but rather because the Greeks’ and Romans’ attitudes to, and understandings of, health and disease are illuminating sources of information about

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Greek and Roman thought and mentality, moral values, and social and cultural history. Indeed, this is one of the reasons for the increasing popularity of ancient medicine as an optional course within Classics and Ancient History degree programmes at British universities. At the same time, the days of Hellenocentrism are largely over, and the tendency of earlier generations of classical scholars and medical historians to privilege certain ‘responses’ over others—such as the Greek, ‘rational’ response over the ‘irrational’, ‘pre-rational’, or ‘magical’ responses of the Babylonians or the Egyptians— or to describe responses to disease in the past by reference to the extent to which they approximate today’s standards, has for the most part been abandoned. A further development is that medical history now also prominently includes the topic of health, both physical and mental health and related topics such as lifestyle, quality of life, well-being, fitness, and ‘flourishing’. This interest is concerned not only with living conditions in the past (both natural, environmental ones and those brought about by human intervention) but also the varying experiences, understandings, and definitions of health through time and their relationship to other social values. Just like disease, ‘health’ is not a self-evident, monolithic concept, but admits of different and sometimes competing understandings, ranging from the absence of disease (however defined) to happiness and mental or spiritual well-being. Consequently, there has been a growing interest among historians of medicine in the ways in which health in the past was experienced and understood, how it was believed to be capable of being maintained, managed, controlled, and enhanced, both privately and in the public domain, and how ‘physical’ and ‘spiritual’ health were defined. This insight is also being applied to the ancient world,17 and this is entirely appropriate, as for most Greek and Roman medical writers—as well as their readers and patients—the preservation and promotion of health was just as much part of the doctor’s business as the treatment of disease, and they went into considerable detail defining health and specifying its requirements. The surviving evidence shows that, during the course of the fifth and fourth centuries bce, health (hugieia) emerged as a key preoccupation for Greek medical writers such as Diocles of Carystus and philosophers such as Aristotle, and a discipline of health called ta hugieina, or ‘matters of health’, was established both for private individuals and for specific groups in society.18 As is well known, the Greek concept of diaita encompassed everything to do with bodily care and what we would call ‘lifestyle’, and it was concerned with the enhancement of ‘quality of life’ as much as with the prevention of disease. One insight that emerges from the study of these Greek medical texts, and which resonates strongly with medical historians of later periods, is the view that ‘health’ and ‘disease’ are not absolute concepts rigidly divided, but relative to individual, social, and environmental circumstances. Likewise, recent interest taken by medical historians in topics such as ‘the body’, ‘disability’, and ‘ageing’ has invited fruitful comparison with Greek and Latin texts—medical as well as non-medical—where these topics have a strong presence, even if their ancient articulations do not always entirely match their modern parallels. As a result of these developments, the ‘intellectualist’ strand in the historiography of ancient medicine has not completely disappeared—that would be inconceivable, if only because most of our evidence represents the ideas and beliefs of a small intellectual

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upper class of ancient society—but it has been modified in a number of ways. The earlier positivist, progressivist, presentist, and teleological perspective has largely been replaced by a more neutral, ‘intellectual-history’ approach that is primarily interested not in whether a particular medical idea is true, interesting, influential, or important from our own perspective or has ‘proved its value’, but in ideas themselves, in how they came about, how they were developed, communicated, and received, and how these processes were related to the historical setting of their time. Thus the intellectual history of ancient medicine has become part of the broader cultural history of the ancient world that contextualizes ideas about health and disease, examines how they arose and functioned, how they gained acceptance, and what justifications were offered for medicine as a profession, as a science and/or as an art, or as an otherwise theoretically founded healing practice. To this research agenda also belong medicine’s changing relationships to other disciplines and fields of professional expertise such as philosophy, religion, and law, with ensuing questions of authority, orthodoxy, pluralism, accountability, and innovation, and the ways in which claims of medical expertise were justified vis-à-vis claims from other domains of social and cultural authority. In addition, there has been a growing interest in other, ‘non-scientific’ or ‘non-intellectual’ responses to health and disease in the Graeco-Roman world. There has been a surge of studies into ancient religious healing practices involving magic, folklore, healing cults, and incubation rituals. This has been accompanied by a growing interest in ‘everyday life’ medicine, in particular the patient’s perspective,19 and there has been a small industry of studies into gender and ‘the body’ in the ancient world.20 There has also been an increasing appreciation of non-literary evidence such as inscriptions, papyri, and material culture;21 bio-archaeology of health and disease in the ancient world not only studies medical instruments, the structure and layout of places where medical care was provided, the material remains of human bodies and nutriment, and the living conditions (social as well as natural), but also uses material culture to deduce implicit medical beliefs and values, from burial practices, for example.22 This brings us to a further, very recent development in the study of ancient medicine, namely the growing awareness of the ways in which canonization has shaped our perspective of the ancient medical world. Relatively speaking, surviving written evidence for medicine in antiquity is substantial, insofar as medical texts have been preserved to a much larger extent than those belonging to other domains of scientific inquiry. Yet it represents only a fraction of what was written, and thus gives us a very selective and potentially distorted view of medical ideas and medical practice in the ancient world. This process of selection already started in antiquity itself, and it has subsequently shaped later perceptions. Thus in medical writing the names of Hippocrates and Galen used to absorb virtually all attention. While for many decades this was simply taken for granted, scholars have come to realize that it is the result of a process of canonization (and historiographical representation) that, in the case of Hippocrates, started very early (possibly already in the early third century bce), when a large number of medical treatises, clearly written by a number of different authors from widely diverging intellectual, geographical, and chronological provenance, were put together under the name of the illustrious doctor

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and medical teacher Hippocrates. This ‘Hippocratic Corpus’ accrued over time and became a canonical body of medical literature that was copied for the purposes of medical learning and instruction and that overruled other medical literature of the same period. This process was supported by the emergence of Greek and Roman biographical, historiographical, and doxographical accounts of Hippocrates and his specific approach to the treatment of disease and the preservation of health.23 Likewise, in the case of Galen, and largely as a result of Galen’s own efforts to disparage rival physicians and to secure his own legacy, many of Galen’s works have survived while those of others have been marginalized, and this has caused most medicine of late antiquity to be labelled as ‘Galenism’. The spell that these two medical corpora have cast over the rest of the material is so great that the words ‘Hippocratic’ or ‘Galenic’ are often used in a very broad sense, sometimes almost to the point of meaninglessness. Only recently has this eclipse been addressed and there is now a growing appreciation of the existence of ‘non-Hippocratic’ medical literature—the writings of other doctors such as Diocles, Praxagoras, Herophilus, Erasistratus, Heraclides, and the contributions from ‘philosophers’ who had medical interests, such as Plato and Aristotle—and of the fact that not all medicine in late antiquity was Galenism. In addition, as said, there are the medical papyri—often reflecting the more ‘mundane’, everyday concerns with health and disease—and the very considerable body of evidence provided by inscriptions and material culture. Furthermore, the study of ancient medicine has long suffered from the same cultural canons as other aspects of the Graeco-Roman world, which caused most attention to be devoted to the ‘classical’ works of fifth-and fourth-century bce Greece and first-century bce–ce Rome, with most other works being dismissed as ‘second rate’ or showing evidence of ‘decline’. In classical studies at large, it was only in the late nineteenth century that scholars began to take the political and cultural achievements of the ‘Hellenistic period’ seriously, and the Roman or ‘Imperial’ period has followed even later. A similar shift has taken place in the study of the medical history of the Hellenistic and Imperial periods, knowledge of which rarely went beyond some great ‘breakthroughs’, such as the discovery of the nervous system by the physicians Herophilus and Erasistratus working in Hellenistic Alexandria (where they were allowed to practise dissection and vivisection of human bodies), the establishment of pulse theory, or the anatomical and physiological theories of Galen. Again, the study of these medical writers is now undertaken from a more explicitly historicizing perspective, situating the developments they were part of in their political, social, and cultural context. Thus an author such as Galen is increasingly being studied in relation to—and as a potential source of information about—the social and cultural life in Rome during the second century and as an exponent of self-styled intellectualism in Roman society.24 Furthermore, ancient medical history has moved even beyond Galen and has taken part in the remarkable shift in classical scholarship towards the study of what is often referred to as ‘late antiquity’, a time frame in which medicine—like most other intellectual activities—was long believed to have come to a halt and remained devoid of any innovation, but where scholarship now increasingly appreciates the changes and developments brought about by the authors of the fourth and fifth century ce.25

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This re-evaluation of the ‘post-classical’ eras has further led to an increasing interest in the role of ‘cultural identity’ in medical ideas and practices in the Graeco-Roman world. Thus there has been extensive engagement with the whole concept of ‘Roman’ medicine, both as a historical and historiographical, medico-anthropological category and with the extent to which it can be contrasted with ‘Greek’ medicine.26 The use of these concepts certainly has historical justification, for it was in these terms that ‘Greek’ medicine was introduced in Rome, where it clashed with very different ideas about health and disease, healing practices, and different forms of social organization; authors such as Pliny the Elder and Celsus do sometimes refer to their own medical ideas and cultural background as ‘Roman’. Yet the distinction is somewhat artificial, and the determination of discretely ‘Roman’ elements in contexts that rely heavily on previous Greek traditions is often problematic. Here, again, the plurality of attitudes and responses to health and disease in the vast territory of the Roman Empire will have been much greater than is suggested by categorizations such as ‘Greek’ versus ‘Roman’, or indeed ‘GraecoRoman’ versus ‘indigenous’, medicine—not to mention early Christian appropriations of ‘pagan’ healing practices alongside the development of distinctly ‘Christian’ beliefs and attitudes to health and sickness.27 Further research into medical provision in the Roman provinces is likely (sources permitting) to yield a more finely grained picture. Even so, this development has had the benefit of furthering interest in the work of Roman medical authors, such as Celsus (first century ce) or Caelius Aurelianus (probably fifth century ce), who used to be studied only insofar as they were believed to reflect, transmit, or ‘translate’ earlier Greek sources but who have proved to have a voice of their own.28 One distinct element is, of course, the language they used and helped to create, and accordingly there have been a number of studies into the formation and development of ‘medical Latin’, both the terminology and discourse, and into the active, original contribution made by authors who used to be regarded as mere translators or compilers.29

Pluralism and competence The net result of the developments outlined above is that scholarship now has a much stronger sense of the plurality and multifacetedness of ancient medicine and is concerned with its variety at least as much as with what unites it.30 One striking example of such pluralism is humoral theory. The famous doctrine of the four humours (blood, phlegm, yellow bile, and black bile), first set out in the Hippocratic treatise On the Nature of Man (c.400 bce), was long believed to have been universally embraced throughout the ancient world and to underlie most medical theories, and it remains one of the bestknown features of Graeco-Roman medicine. Yet in the days in which it was first articulated, the four-humour theory was just one among many physiological doctrines and its specific origins are far from clear—at any rate they may have been less intellectually respectable than used to be assumed. As early as the fifth century bce (the time when the

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first Hippocratic treatises were written), there were a large number of varying physiological theories around, with different bodily fluids being identified, and different roles, functions, locations, and movements being ascribed to them. Thus in some of the pathological writings of the Hippocratic Corpus, bile and phlegm often play the role of pathogenic agents rather than natural constituents; in Aristotelian physiology, phlegm, yellow bile, and black bile are classed as ‘residues’ of nutriment along with other waste products, devoid of any purpose and potentially harmful to health if not disposed of properly; and in Plato’s Timaeus the picture is yet again different, with further distinctions being made within the category of black bile. Furthermore, several medical schools of thought—especially those of Erasistratus, Asclepiades, and the Methodists—did not adopt a humoral theory at all. The canonization of the four-humour theory and its subsequent standardization in late antique and early medieval thought—when it was connected with the theory of the four ‘temperaments’, sanguine, phlegmatic, choleric, and melancholic—was largely the result of the fact that Galen in the second century ce elevated it to the authoritative model, thereby effectively and powerfully eliminating or marginalizing rival theories.31 Pluralism not only pertains to ideas and doctrines about health and disease, but also to questions of authority and professionalization. Within a group or society, there can be disagreement or conflict about who possesses the competence, skill, and authority to determine what is health and what is sickness, about the criteria on which such determinations are based and the ways in which they are applied and validated. The well-known competitive setting of ancient Greece displayed a considerable number of rival perspectives, unparalleled by any other ancient civilization, when it came to the question of who decides, and by what authority, whether someone is healthy or ill—the patient versus the doctor, the individual versus the society, medicine or philosophy, subjective experience versus objective ‘scientific’ definition, etc.—and what action should be taken to cure the sick or to prevent the healthy from falling ill. We can obtain an impression of such competing claims to competence in the area of health and disease from the polemical treatises in the Hippocratic Corpus. Thus On the Sacred Disease (c.425 bce) not only criticizes magical beliefs and practices about disease, but it also, interestingly, detaches disease (nosos)—and especially what we would call mental disease—from the religious and moral domain: you do not get epilepsy because you have done something wrong, offended the gods, or harmed other people, the author argues, but because there is something wrong with your brain; and epilepsy is not a miasma, a pollution caused by some kind of moral, religious, or ritual offence that needs to be rectified by religious or ritual practice, but a natural phenomenon that has a nature and a cause (phusis kai prophasis) and that can be cured by means of diet. A similar polemical debate defining the area of competence of medical writers with regard to health can be found in the Hippocratic work On Regimen (early fourth century bce), which marks off the area of medical prognosis on the basis of an individual’s dreams from that of divination. The author emphatically separates his own prophylactic response to the health challenge posed by the imminent disease signified in the patient’s dreams—and skilfully interpreted by the prognostic dietician—from the religious

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instructions of the diviners. The reverse, however, is also found, for ancient literature has also preserved rival accounts of miracle healers such as the pre-Socratic philosopher Empedocles (who has sometimes been thought to be the implicit target of several Hippocratic authors’ polemics) putting the doctors of his day to shame for their incompetence in explaining, for example, the resuscitation of a woman who did not breathe for thirty days, or in dealing with the epidemic disease of the Sicilian town of Selinunte. Epidemic disease is a good example of the one area that remained controversial all through what has been called ‘the Greek age of reason’. For a continuing characteristic of Greek thinking about health and disease is to relate the health or sickness of the individual to that of his or her surrounding environment. That relationship can go in two directions: according to the ‘archaic’ (or ‘pre-Hippocratic’) paradigm, the sickness of a city can be caused by the religious offence of one of its inhabitants (witness Oedipus), health being maintained or restored in response to the justice and wisdom of its inhabitants and leaders. However, the cause–effect relationship can also be reversed: the health or disease situation can be regarded as the result of healthy or unhealthy environmental factors. This is what the writers of the Hippocratic Epidemics called the katastasis, the health state of a particular place during a particular time or season as determined by climate and other factors. Here, for the first time in history, we find attempts at what we would call ‘demographic’ medical history, describing collective experiences of health and disease and specifying according to social factors, such as age, gender, occupation, and background.

Mental health, illness, and disability No aspect of human health was more surrounded by controversy and by competition for authority than mental health, where more traditional, religious patterns of explanation remained forceful alongside secular explanations and where rival claims to competence were raised in Greek medicine, philosophy, literature, and religion. Again, scholarly realization of this plurality of responses in the Greek world parallels broader developments in the historiography of mental illness, or what was perceived as such. The problem already begins with the definition: the very notion of ‘mental illness’, and the distinction between mental and physical health and illness, is subject to controversy or at least different understandings. In Greek tragedy, for example, representations of madness are, of course, frequent, and they are often attributed to the anger or wrath of a divine force, but the standard term for these mental afflictions is nosos, ‘disease’, without explicit indication of the area affected. In the plays of Euripides and Sophocles, there seems to be no categorical distinction among the kind of mental frenzy that characterizes Heracles, the mysterious chronic illness of Philoctetes, or the lovesickness of Phaedra: they are all divine afflictions, and cure, if at all possible, is something only the gods can effect. When there is reference to herbal treatment (as in the case of Philoctetes), this seems to be intended in terms of soothing and pain relief rather than cure.

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With regard to the writers of the medical treatises attributed to Hippocrates, there is a genuine question as to whether they had a concept of mental illness. Of course, they describe disturbances of the mental functions, and they have a rich vocabulary for this, much of which has remained influential in medical terminology until very recently. However, there is no separate category of mental health or mental illness as such: conditions like mania, phrenitis, or melancholia are attributed to physical causes such as bile or phlegm, and the treatment is accordingly conducted in almost entirely physical terms. The same applies to mental health. Thus the author of On the Sacred Disease discusses different forms of ‘madness’ (mania) due to bile or phlegm affecting the brain and its connections with the rest of the body; and mental health consists entirely of an unimpeded functioning of the brain and an uninterrupted flow of breath through the vessels of the body: for these reasons I believe that the brain is the most powerful part in a human being. As long as it is healthy, it is the interpreter of what comes to the body from the air. Consciousness is provided to it by the air. The eyes, ears, tongue, hands and feet carry out what the brain decides, for throughout the whole body there is a degree of consciousness proportionate to the amount of air which it receives. As far as understanding is concerned, the brain is the part that transmits this, for when a man draws in breath it first arrives at the brain, and from there it is distributed over the rest of the body, having left behind in the brain its best portion and whatever is intelligent and has discernment (gnômê). For if the air arrived first at the body and subsequently at the brain, it would leave the power of discerning thinking behind in the flesh and in the blood-vessels; it would reach the brain in a hot and no longer pure state but mixed with moisture from the flesh and from the blood so that it would no longer be accurate. I therefore state that the brain is the interpreter of understanding. (On the Sacred Disease, chs. 16–17)

Interestingly, the author nowhere uses the word ‘soul’ (psuchê) and he locates all mental processes (thinking, emotions, and sense perception) in physical organs and tissues, among which the brain takes pride of place. His project to ‘naturalize the mind’ is related to a wider tendency in Greek thought of his time to provide natural explanations for phenomena hitherto explained by reference to direct divine action—not only thunder or earthquakes, but also manifestations of madness and epileptic fits. Like other Greek thinkers, he is looking for the ‘nature’, the phusis, of things; and like other medical writers, he is seeking the nature of man: what is man, how is he composed, how does he function and work? And what is the nature of human failure, weakness, disease—bodily as well as mentally? The author of On Regimen discusses mental health and illness in similar physical terms: As to what is called intelligence of the soul, and senselessness, matters are as follows. The moistest fire and the driest water, when mixed in the body, result in the greatest intelligence, because the fire has the moisture from the water, and the water the dryness from the fire. . . . The soul mixed of these is most intelligent and has the best memory. . . . If there is a mixture of the purest fire and water, and the fire falls a little

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short of the water, such persons too are intelligent, but fall short of the former mixture. . . . Such souls are fairly constant in their attention, and this kind of person under the right kind of regimen may become more intelligent and keen than is natural. Such a person benefits from using a regimen inclining rather to fire with no surfeit either of food or drinks. So he should take sharp runs. . . . but it is not beneficial for him to practise wrestling, massage or like exercises. . . . walks, however, are beneficial. . . . it is also beneficial to practise (induced) vomiting. . . . unction is more beneficial to such people than baths, and sexual intercourse should take place more often when the onsets of water occur, less, however, at the onsets of fire. . . . But if the fire is mastered by a greater extent by the water in the soul, we have cases of what are called by some ‘senseless’ people, and by others ‘grossly stupid’. . . . They weep for no reason, fear what is not dreadful, are hurt by what does not affect them, and their sensations are really not at all those that sensible persons feel. These people benefit from vapour baths followed by purging with hellebore, and to practise the same regimen as in the previous case. Reduction of flesh and drying are called for. (On Regimen 35, extracts; trans. W. H. S. Jones (Loeb Classical Library), modified)

The author identifies a number of different mental states or conditions on a scale from an optimum to a pessimum, and thus presents a good example of the scalar, gradualist view of health characteristic of Greek medicine. However, these variations are ultimately due to the specific physical basis of the individual as characterized by the peculiar proportion between fire and water, which admits of seemingly endless variation. A further striking aspect here is that mental health and mental illness can be influenced by dietary measures such as eating and drinking, exercise, working and leisure, sexual activity, and sleeping and waking patterns. Health, including mental health, is capable of being managed, maintained, restored, or enhanced; and the expert who has the ability to do so is the dietician, who has discovered for each person the regimen that ensures the greatest chance of steering clear of illness. This ‘materialist’ approach to mental health and illness was to have a long history throughout Graeco-Roman antiquity. Yet it met with considerable resistance from philosophers. Thus in Plato’s Timaeus we find ‘diseases of the soul’ distinguished from ‘diseases of the body’ (86B2 ff.).32 And this is not surprising, considering Plato’s general views on the uncomfortable relationship between soul and body. Nor is it surprising that mental illness is attributed to bad management of the body, and mental health a matter of keeping to a regimen in which the body and its influence on the soul through passion and desire is kept under strict regulation. Mental health for Plato is, above all, a matter of morality, backed up by a frugal lifestyle and guided by reason, if not one’s own, then that of one’s leaders in the city or community. The healthy body is for Plato essentially not more than a substrate, a material basis on top of which psychic, spiritual well-being can take place. The body does not contribute, let alone constitute, an aspect of this mental health; at best, it is neutral, but in most cases it poses a challenge to the good life as defined by the philosophers. A more integrated account of mental and physical health, and arguably a more successful attempt to combine philosophy and medicine, can be found in Aristotle.33 For, although Aristotle was the pupil of Plato, he was also the son of a court physician and in

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his work he displays great interest in medical matters. As is well known, the most fundamental aspect of Aristotle’s psychological theory is his opinion that soul and body are not separate entities but two mutually complementary and inseparably connected aspects—the ‘form’ and the ‘matter’—of one and the same living being. Aristotle advances a psycho-physical theory of emotions like anger, for which he cites two complementary definitions, a ‘seething heat in the region of the heart’ and ‘a desire for retaliation’ (On the Soul 403a30–31): these are two complementary accounts of the same emotional state, the former referring to the physical, the latter to the psychological. Accordingly, Aristotle takes a more neutral approach than did Plato with regard to the emotions; they have their place within human nature, and a regulated expression or even outpouring of these emotions can be conducive to health and mental stability, as his famous theory of catharsis testifies. Mental health for Aristotle is a combination of natural and cultural factors, physical as well as psychological and moral; and on the basis of his definition of bodily health as a ‘good balance’, a summetria or eukrasia, between the constituent factors, he likewise understands mental health as a balance, an eukrasia, between constituent factors such as the elementary qualities and the specific ratios between heat and cold. Thus Aristotle attributes cognitive and psychological virtue to material factors being conducive to, and constituents of, a healthy, undisturbed exercise of ‘mental’ faculties. He mentions variations in the blood, in the quality of the skin, and even in the size of the heart and the brain being correlated to variations in keenness of perception, thinking, and the stability of one’s emotions. Behind this is the notion of krasis, the physical ‘mixture’ or ‘proportion’ of elements or elementary qualities that Aristotle has adopted from Greek medical theory. Aristotle also allows dietary and geographical factors to play their part: he notoriously speaks of variations in the environment as constituting variations in intellectual and moral excellence. Likewise, Aristotle attributes failure to achieve mental health and moral excellence to the influence of disturbing physical, environmental, and dietary factors, as in his well-known discussion of akrasia, lack of moral self-restraint. His account of this moral deficiency and its capacity of being ‘cured’ is cast in strikingly medical terms that go beyond analogy: The unrestrained person is so constituted as to pursue bodily pleasures that are excessive and contrary to the right principle yet without being convinced he ought to do so, whereas the profligate is convinced that he ought to pursue them because he is so constituted as to pursue them. Therefore the former can easily be persuaded to change his mind, but the latter cannot. . . . The unrestrained person knows the right in the sense not of one who consciously exercises this knowledge, but only as a person who is asleep or drunk can be said to know something. . . . Cure is easier in the case of unrestrained people of the melancholic type than in the case of people who deliberate as to what to do but fail to keep to their decision. And those who have become unrestrained by habit are more easily cured than those who are unrestrained by nature, since habit is easier to cure than nature. . . . Bodily pleasures appear more desirable than others because pleasure drives out pain, and excessive pain leads people to seek excessive pleasure, and bodily pleasure generally, as a

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cure. . . . Bodily pleasures are sought because of their intensity, by people who are incapable of enjoying others. . . . many people being constituted in such a way that a neutral state of feeling is to them positively painful. Similarly the young are in a condition resembling intoxication, because they are growing; and youth is pleasant in itself. Melancholics are in constant need of such cure: their bodily mixture (krasis) keeps them in a constant state of irritation, and their appetites are continually active; hence any pleasure, if strong, drives out the pain. (Nicomachean Ethics VII 8–14, 1151a10–1154b18, excerpts; trans. H. Rackham (Loeb Classical Library), modified)

Clearly, Aristotle regards the state of akrasia as a medical condition, a kind of physical addiction that not only disables individuals and renders them incapable of normal healthy functioning, but that is also in need of treatment (therapeia) and capable of being cured (iatreia), though to varying extent, through a combination of physical regimen and moral or spiritual guidance. Thus we see philosophy competing with medicine for the role of authoritative guide to health, mental as well as physical, and diagnostic as well as therapeutic. This competition continued throughout antiquity. Thus the Stoics and Epicureans—themselves ‘materialists’ when it came to their views of mental and psychological activities—offered their philosophical theories as ‘therapies of the mind’, while Galen in his influential treatise ‘That the Faculties of the Soul follow the Mixtures of the Body’ argued that even intellectual and cognitive performance can be enhanced or weakened by means of dietetic and pharmacological treatment, thus implying that psychological health and wellbeing are the domain of the physician as much as the philosopher. However, the controversial question remained whether this applies to all mental states or whether some conditions are ‘beyond’ bodily influence and curable by psychological or spiritual means only.

Conclusion The study of ancient medicine is flourishing, especially in the Anglophone world, where it has been discovered by classicists and ancient historians as a rich and in many ways still underexplored area of study and as a fruitful source of information about GraecoRoman thought, culture, and mentality. Medical authors have attracted growing interest from students of ancient philosophy for their contribution to debates about epistemology, scientific methodology, and the mind–body problem, and for their use of philosophical concepts and procedures. Likewise, students of ancient literature and linguistics have appreciated the richness of ancient medical writing for its use of rhetoric and metaphor, and the development of medical terminology. Furthermore, ancient medicine has shown itself to be an illuminating area for what one may call the cultural history of the Graeco-Roman world and the study of ancient medicine presents a powerful example of the benefits of an integrated approach, combining philological, philosophical, historical,

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and archaeological methods of inquiry. The study of Graeco-Roman medicine has already profited significantly from connections and comparisons with the study of the history of medicine, science, and culture from other time frames and other parts of the world. At the same time, there still is a large amount of work to be done in the more traditional areas of editing, translating, and commenting on medical texts and the interpretation of ancient medical ideas. The great challenge for future scholarship is to address the subject in ways that open it up even further to these neighbouring disciplines, while preserving the characteristic virtues of sound classical scholarship.

Notes 1. The word ‘Hippocratic’ is used here and throughout this chapter in the sense of ‘attributed, at some stage during its transmission, to Hippocrates’. For none of the treatises collected under the rubric ‘Hippocratic Corpus’ has the authorship of Hippocrates been satisfactorily proven. 2. E. Littré, Oeuvres complètes d’Hippocrate, 10 vols (Paris, 1839–61); C. G. Kühn, Claudii Galeni opera omnia, 22 vols (Leipzig 1821–33). 3. P. J. van der Eijk, Medicine and Philosophy in Classical Antiquity (Cambridge: Cambridge University Press, 2005), 1–8; V. Nutton, ‘Ancient Medicine: Asclepius Transformed’, in C. Tuplin and T. Rihll (eds), Science and Mathematics in Ancient Greek Culture (Oxford: Oxford University Press, 2002), 242–55; V. Nutton, ‘Ancient Medicine, from Berlin to Baltimore’, in F. Huisman and J. H. Warner (eds), Locating Medical History (Baltimore: Johns Hopkins University Press, 2004), 115–38; G. E. R. Lloyd, ‘The Transformations of Ancient Medicine’, Bulletin of the History of Medicine, 66 (1992), 114–32. 4. For an account of pluralism’s impact on medical historiography, see W. Ernst (ed.), Plural Medicine, Tradition and Modernity 1800–2000 (London: Routledge, 2002). 5. P. J. van der Eijk, H. F. J. Horstmanshoff, and P. H. Schrijvers (eds), Ancient Medicine in Its Socio-Cultural Context, 2 vols (Amsterdam/Atlanta: Rodopi, 1995). 6. Early exceptions to this pattern are: F. Kudlien, Der Beginn des medizinischen Denkens bei den Griechen (Zurich/Stuttgart, 1967); E. J. Edelstein and L. Edelstein, Asclepius, 2 vols (Baltimore: Johns Hopkins University Press, 1945); H. Sigerist’s History of Medicine (Oxford/ New York: Oxford University Press, 1961), volume 2 of which explicitly considered healing practices beyond the texts of learned medicine. 7. Helen King, The Disease of Virgins: Green-Sickness, Chlorosis and the Problems of Puberty (London: Routledge, 2003); Helen King, Midwifery, Obstetrics and the Rise of Gynaecology (Aldershot: Ashgate, 2007); Vivian Nutton, Theories of Fever from Antiquity to the Enlightenment (London, 1981); Vivian Nutton, From Democedes to Harvey: Studies in the History of Medicine (London: Ashgate, 1988); Dominic Montserrat, Changing Bodies, Changing Meanings: Studies into the Human Body in Antiquity (London: Routledge, 2004). 8. G. E. R. Lloyd, Adversaries and Authorities (Cambridge: Cambridge University Press, 1996); G. E. R. Lloyd and Nathan Sivin, The Way and the Word (New Haven, CT: Yale University Press, 2002); G. E. R. Lloyd, The Ambitions of Curiosity (Cambridge: Cambridge University Press, 2002). 9. M. D. Grmek, Diseases in the Ancient Greek World (Baltimore: Johns Hopkins University Press, 1989); R. Sallares, The Ecology of the Ancient World (London: Duckworth, 1991);

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10. 11.

12. 13.

14.

15.

16. 17. 18. 19. 20.

21.

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R. Sallares, Malaria and Rome (Oxford: Oxford University Press, 2002); Piers Mitchell, Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon (Cambridge: Cambridge University Press, 2004); Vivian Nutton (ed.), Pestilential Complexities: Understanding Medieval Plague (London: Routledge, 2008). J. Longrigg, Greek Rational Medicine (London, 1993); J. Jouanna, Hippocrates (Baltimore: Johns Hopkins University Press, 1999). B. Wickkiser, Asklepios, Medicine, and the Politics of Healing in Fifth-Century Greece (Baltimore: Johns Hopkins University Press, 2008); J. W. Riethmüller, Asklepios, Heiligtümer und Kulte, Studien zu antiken Heiligtümern (Heidelberg: Winter, 2005); C. Nissen (ed.), Entre Asclépios et Hippocrate. Étude des cultes guérisseurs et des médecins en Carie, Kernos Supplements 22 (Liège, 2009). D. Sedley, Creationism and Its Critics in Antiquity (Berkeley: University of California Press, 2008). H. F. J. Horstmanshoff and M. Stol (eds), Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine (Leiden: Brill, 2004); M. J. Geller, Ancient Babylonian Medicine: Theory and Practice (London: Wiley Blackwell, 2010). This touches on the broader question of the relationship between the history of medicine and the history of science: while the former was long regarded as a species of the latter, many medical historians nowadays prefer to regard their discipline as partly overlapping with, but not necessarily being completely subsumed by, history of science. Examples include M. Frede, Essays in Ancient Philosophy (Oxford: Oxford University Press, 1987); J. Barnes, ‘Galen on Logic and Therapy’, in R. J. Durling and F. Kudlien (eds), Galen’s Method of Healing (Leiden: Brill, 1991), 50–102; R. J. Hankinson (ed.), The Cambridge Companion to Galen (Cambridge: Cambridge University Press, 2008). P. Unschuld, Was ist Medizin? (Munich: Beck, 2003), distinguishes between ‘Medizin’ and ‘Heilkunde’. H. King (ed.), Health in Antiquity (London: Routledge, 2005); M. C. D. Peixoto (ed.), Saúde dos Antigos—Reflexões Gregas e Romanas (São Paulo: Ediçoes Loyola, 2008). P. J. van der Eijk, Diocles of Carystus (Leiden: Brill, 2000–1); G. Wöhrle, Studien zur Theorie der antiken Gesundheitslehre (Stuttgart: Steiner, 1990). H. F. J. Horstmanshoff, Patiënten zien. Patiënten in de antieke geneeskunde (Leiden: Leiden University Press, 2004). H. King, Hippocrates’ Woman (London: Routledge, 1998); L. Dean-Jones, Women’s Bodies in Greek Science (Oxford: Oxford University Press, 1994); R. Flemming, Medicine and the Making of Roman Women (Oxford: Oxford University Press, 2000). E. Samama, Les médecins dans le monde grec: sources épigraphiques sur la naissance d’un corps medical (Paris: Droz, 2003); N. Massar, Soigner et servir: histoire sociale et culturelle de la médecine grecque à l’époque hellénistique (Paris: De Boccard, 2005); M.-H. Marganne, ‘The Role of Papyri in the History of Medicine’, Histoire des sciences médicales, 38 (2004), 157–64; I. Andorlini Marcone, Greek Medical Papyri (Florence, 2001); Andorlini Marcone, ‘L’apporto dei papiri alla conoscenza della scienza medica antica’, Aufstieg und Niedergang der römischen Welt II.37.1 (1993), 458–562; D. Leith, ‘The Antinoopolis Illustrated Herbal (P. Johnson + P. Antin. 3. 214 = MP3 2095)’, Zeitschrift für Papyrologie und Epigraphik, 156 (2006), 141–56; A. E. Hanson, ‘Greek Medical Papyri from the Fayum Village of Tebtunis: Patient Involvement in a Local Health-Care System?’, in P. J. van der Eijk (ed.), Hippocrates in Context (Leiden: Brill, 2005), 387–402; R. Jackson, Doctors and Diseases in the Roman Empire (London: British Museum, 1988); E. Künzl, Medizin in der Antike (Darmstadt: Wissenschaftliche Buchgesellschaft, 2002).

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22. C. Roberts et al., ‘Health and Disease in Greece: Past, Present and Future’, in King (ed.), Health in Antiquity, 32–58; P. A. Baker, Medical Care for the Roman Army on the Rhine, Danube and British Frontiers from the First through Third Centuries AD (Oxford: Oxbow, 2004); P. A. Baker and G. Carr (eds), Practitioners, Practices and Patients: New Approaches to Medical Archaeology and Anthropology: Conference Proceedings (Oxford: Oxbow, 2002). 23. P. J. van der Eijk (ed.), Ancient Histories of Medicine: Essays in Medical Doxography and Historiography in Classical Antiquity (Leiden: Brill, 1999); P. J. van der Eijk, ‘On “Hippocratic” and “Non-Hippocratic” Medical Writings’, in L. Dean-Jones and R. J. Hankinson (eds), What Is Hippocratic about the Hippocratic Corpus? (Leiden: Brill, in press). 24. H. Schlange-Schöningen, Die römische Gesellschaft bei Galen: Biographie und Sozialgeschichte (Berlin: De Gruyter, 2003). 25. M. Formisano, Tecnica e scrittura (Rome: Carocci, 2001). 26. V. Nutton, ‘Roman medicine: tradition, confrontation, assimilation’, in Aufstieg und Niedergang der römischen Welt II.37.1 (1993), 49–78. 27. O. Temkin, Hippocrates in a World of Pagans and Christians (Baltimore: Johns Hopkins University Press, 1991); D. Amundsen, Medicine, Society and Faith in the Ancient and Medieval Worlds (Baltimore: Johns Hopkins University Press, 1996); R. W. Sharples and P. J. van der Eijk, Nemesius: On the Nature of Man (Liverpool: Liverpool University Press, 2008), 11–14. 28. G. Sabbah and P. Mudry (eds), La médecine de Celse (Saint-Etienne: Centre Jean-Palerne, 1994); P. Mudry (ed.), Le traité des Maladies aiguës et des Maladies chroniques de Caelius Aurelianus: Nouvelles Approches (Nantes: Institut Universitaire, 1999). 29. D. R. Langslow, Medical Latin in the Roman Empire (Oxford: Oxford University Press, 2006). 30. On the pendulum swing between stressing unity and stressing diversity in the historiography of ancient medicine, see van der Eijk, ‘On “Hippocratic” and “Non-Hippocratic” Medical Writings’. 31. J. Jouanna, ‘La postérité du traité hippocratique de la Nature de l’homme: la théorie des quatre humeurs’, in C. W. Müller, C. Brockmann, and C.W. Brunschön (eds), Ärzte und ihre Interpreten (Leipzig: Saur, 2006), 117–41. 32. L. Grams, ‘Medical Theory in Plato’s Timaeus’, Rhizai, 6 (2009), 161–92. 33. P. J. van der Eijk, ‘Aristotle’s Psycho-Physiological Account of the Soul–Body Relationship’, in J. P. Wright and P. Potter (eds), Psyche and Soma: Physicians and Metaphysicians on the Mind–Body Problem (Oxford: Oxford University Press, 2000), 57–77.

Select Bibliography Van Der Eijk, P. J., Medicine and Philosophy in Classical Antiquity (Cambridge: Cambridge University Press, 2005). —— , H. F. J. Horstmanshoff, and P. H. Schrijvers (eds), Ancient Medicine in its SocioCultural Context, 2 vols (Amsterdam/Atlanta: Rodopi, 1995). —— (ed.), Hippocrates in Context (Leiden: Brill, 2005). Grmek, M. D., Diseases in the Ancient Greek World (Baltimore: Johns Hopkins University Press, 1989). —— , Storia del pensiero medico occidentale, vol. 1: Antiquità e medioevo (Bari: Laterza, 1993).

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Hankinson, R. J., The Cambridge Companion to Galen (Cambridge: Cambridge University Press, 2008). Jackson, R., Doctors and Diseases in the Roman Empire (London: British Museum, 1988). Jouanna, J., Hippocrates (Baltimore: Johns Hopkins University Press, 1999). Lloyd, G. E. R., In the Grip of Disease (Oxford: Oxford University Press, 2003). Nutton, V., Ancient Medicine (London: Routledge, 2004).

chapter 3

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When a finger is lost, is this a disease in number or in quantity? Are haemorrhoids natural? Should a child born with a major malformation of the foot be described as ill ut nunc (‘as of now’, contingently) or simpliciter (‘simply’, by inference)? Are boys more vulnerable to gout than eunuchs? Is black urine necessarily a sign of death? Is the virtue of nutrition essentially the same as the virtue of growth? Are there two kinds of apoplexy, or three? These were among the questions debated in their writings—and probably also in their classrooms—by some of the most respected academic physicians of medieval Europe.1 Such is scholastic medicine. The term ‘scholastic’ originally referred neutrally to the concerns of first the cathedral schools and then the universities, from around the eleventh century on. It became though, and has remained, a term of abuse. Scholastic medicine was criticized even in its own time for sophistry—‘numberless problems and useless arguments’, as Roger Bacon put it in the mid-thirteenth century.2 Not least in its propensity for quantifying, this medicine seems to offer an equivalent of the medieval theologians’ supposed obsession with angels dancing on a pinhead. The virtus dormitiva that, satirically, ‘explains’ the power of opium in Molière’s Le malade imaginaire of 1673 had a serious antecedent: the virtus digestiva responsible for digestion in some thirteenth-century discussions. By Molière’s time, Renaissance humanism had had its say on the scholastics. The medical humanists had sought to return to the ‘pure’ sources of knowledge: Greek texts untainted by the vocabulary and ideas that medieval Europe had taken, in Latin translation, from Islamic authorities. Because of its ‘corrupt’ language, scholastic medicine came to be equated with barbarism. Thus was ‘medieval medicine’ invented: part of the larger process by which the Renaissance defined the ‘dark’ intermediate period between itself and the classical world it so admired. There is, however, far more to medieval medicine than its seeming absurdities. Scholastic medicine is the primary medicine of the Middle Ages in two senses. It is the first to have been identified as ‘medieval’—by the humanists. And second, from our

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point of view, it is the one form of medicine wholly characteristic of the period—even though much of it survived Renaissance prejudice. Although it could flourish elsewhere, scholastic medicine had an institutional home that was distinctively medieval. This was, to begin with, the schools of the twelfth century, especially (though not exclusively) those of Salerno in southern Italy; then, from the thirteenth century onwards, the medical faculties that emerged, to rank with faculties of theology and law, in the universities pre-eminently of Italy and France.3 That institutional setting was novel. First, it was geographically more widespread and homogeneous (despite clear regional particularities) than anything to be found in Graeco-Roman antiquity, with its few, disparate, centres of medical education outside the famed Alexandria. With the setting, secondly, came a distinctive teaching style. It owed much to the syllabus of Alexandria but again developed in new ways. It had a core collection of basic Hippocratic and Galenic texts in Latin that, together with a synopsis of medical theory translated from the Arabic, formed the standard introduction to medicine from the twelfth century to the earlier sixteenth. It also involved oral lectures, debates, and written commentaries on more substantial works, particularly the Latin Canon of Avicenna, as he was known in the Latin West (Ibn Sinā, d. 1037), and Galen on anatomy and physiology, supported from the fourteenth century by the dissection of human beings, reviving procedures last evidenced in Hellenistic Alexandria.4 Thirdly, scholastic medicine, the ‘primary’ medieval medicine, was embedded in a consistent range of medieval disciplines. It was a scientia in the Aristotelian sense of claiming to offer certain and universally true knowledge, derived, by syllogistic reasoning, from accepted premises. Indeed its relationship to the Aristotelian physical and ethical works that became available to European scholars in Latin translation was so close that many ‘disputed questions’ (akin to those instanced at the start) focused on the divergences between Galen and Aristotle. That is why superior doctors, previously medici in Latin, arrogated Aristotelian physica to themselves and, during the twelfth century, became ‘physicians’.5 However, if scholastic medicine was a science, it could also claim to be an art, especially because of the regular links between courses in medicine and those in the ‘liberal arts’, the fundamental linguistic, logical, and mathematical disciplines. All these ingredients derived from classical antiquity. But their combination within the university was new to the Middle Ages. This was a philosophically based, coherent set of medical ideas. It displayed emphases that marked it out from its ancient sources—for instance, in the prominence it gave to complexion or temperament (the balance of the elemental qualities of hot, cold, wet, and dry), rather than to the Hippocratic humours. A further distinctive aspect of scholastic medicine is the extent to which it achieved ‘market dominance’. Unlike classical antiquity, with its competitive medical traditions— ‘rationalist’, ‘methodist’, ‘empiricist’, and so forth—and unlike the sixteenth century, in which Paracelsianism began to offer a credible alternative to Galenism, medieval scholastic medicine had no serious intellectual rivals. A relatively few individuals rejected it

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outright. But there were no alternative schools of strictly medical thought. In the aftermath of the fourteenth-century plague epidemics (for which there were really no remedies), ‘occult’ forms of medicine, involving alchemy and astrology, became increasingly fashionable. Yet in no sense did they (or the plague itself) dethrone the scholastics.6 Indeed, university-type medicine remained the gold standard from the later thirteenth century onwards.7 A small minority of practitioners had followed a university course. A minority of that minority had proceeded to a medical degree. Yet this tiny sliver of the whole not only created the ‘taste’ by which medicine was enjoyed among the courtiers and urban elites of Europe, but used its political and therapeutic credentials to establish itself at the top of a well-defined hierarchy of healers—a hierarchy only very partially reinforced by systems of licensing. Below the university physicians stood the ‘rational’ surgeons, who had quickly emulated them in acquiring an intellectual pedigree. Below them, the various kinds of ‘empiric’, who relied on ‘the facts’ because they allegedly had no guiding theory. And, at the bottom, village quacks, cunning women, magicians, midwives—unspeakable in their ignorance and superstition, according to the view from the summit. Yet, despite its theorizing, academic medicine was no less practical in orientation than the healing offered by these ‘uneducated’ villagers. Unlike late antique Alexandria, there was no divorce between theory and practice in the medieval university. Most of the professors’ income derived from lucrative private practice. They did not entirely specialize in diseases of the rich. Taddeo Alderotti (d. 1295), the most celebrated of the professors at the University of Bologna (the Johns Hopkins of the late thirteenth century), offered a special laxative ‘for the noble and delicate’.8 Yet his patients ranged widely in status, from a blacksmith to a Venetian doge. Such a man would have been astonished to be told that the questions debated in his writings proved him out of touch with his patients. His banker would also have been surprised, as would his pupils, for whom clinical experience was almost certainly part of their degree course. Experience without the application of reason was useless—but so was the converse. Finally, his patients would have been surprised. This was a type of medicine fully aware of its need to gain their confidence and complicity. The best university physicians, for all their philosophical firepower, held a modest expectation of what they, and indeed medicine in general, could achieve. Our modern experience of biomedicine, with its interventionist bias, coupled with stereotypes of pre-modern medicine as fixated on bleeding and purging, inclines us to suppose that medieval practitioners were therapeutically active. While some may have been so aggressive, evacuating the patient in all directions, the norm was much less dramatic, and, by biomedical standards, less damaging. Preventative medicine—regimen, broader in scope than modern ‘diet’, and including psychological regulation—ranked high.9 Treatment for illness, similarly, consisted in good regimen and, for the most part, mild medication: hardly more than nursing and herbal infusions. And talk. These physicians, trained in rhetoric as a prerequisite of medical study, said more than they did. They offered the consolation of philosophically underpinned prognosis.10 They made sense of patients’ woes even when—perhaps especially when—they could not end

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them. They interpreted signs and symptoms and enfolded them into a narrative that the patient could grasp and accept. As represented in both Latin and an ever-increasing number of translations into the vernacular, this medicine became extremely popular, perhaps more so than any one medical school of thought in antiquity, that of Galen included. Just one example: in 1304 Gueraula de Codines, a ‘wise woman’ living near Barcelona, was arraigned by her bishop for irregular medical practice. Asked if she knew any medicine, ‘she said no, except that she could diagnose a patient’s illness from his urine . . . citrine urine indicates a continued fever, vermeyla a tercian fever, rubia the first stages of a quartan fever . . . and white spumous urine indicates an aposteme’. She said she had learned this from a foreign doctor.11 Gueraula’s case shows one of the outer ripples of scholastic medicine. She had absorbed a surprising amount. Her uroscopy was hardly different from that of her monarch’s physicians, who appraised the royal water each morning, and it derived ultimately from a substantial technical literature that included a treatise ascribed to the great Catalan physician Arnald of Villanova. In her bravura terminology, meant to impress clients, she was, however unwittingly, following Arnald’s advice to doctors unable to interpret a urine specimen: diagnose obstruction of the liver, and use the word oppilatio, ‘because they do not understand what it means’.12 Michael McVaugh has suggested that learned medicine triumphed less through pressure from above—professional self-assertion on the part of university physicians—than in response to popular demand. Acquaintance with the basics of scholasticism could thus be far more widespread in medieval society than direct testimonies show. Bookish physicians and ‘empirics’ might be better seen as the extremes of a single, albeit diverse, medical culture, than as representatives of two separate camps. ‘Traditional remedies could coexist with Galenic theory in the village empiric as well as the university master.’13 In all these ways, European scholastic medicine, the primary form of medieval medicine, was distinct from that of antiquity, despite its thorough-going Galenism. It was also, in some respects, distinct from that of the Renaissance and the early modern period, even though in intellectual terms the Renaissance can be seen as scholasticism continued with modifications, evident in Renaissance printed editions of scholastic commentaries and questions on which modern historians must still in most cases rely.

Historiography Having now plunged into the subject at its seemingly most abstruse, and having begun to register the surprising successes of scholastic medicine, we can look more closely at the scholarship that has made this re-evaluation possible. When the history of the historiography of medieval medicine comes to be written, it may be found to have followed a slightly different trajectory from that of the study of more recent periods.14 Pioneers in

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the relatively new academic field of medical history (and pre-eminently Karl Sudhoff, 1853–1938) began their work in the late nineteenth century, principally editing texts. What made their work historical rather than medical was the fact that the humoral system of the Hippocratic–Galenic tradition had ceased to be living medicine—but only recently. Now no longer a source of perennial wisdom, the ‘ancients’ became an object of scholarly enquiry. Yet perhaps to a much lesser extent than was evident in the historiography of eighteenth- and early-nineteenth-century medicine, medievalists could sidestep the more blatant triumphalism that developed—historical writing overpopulated by great men striding towards ‘truth’. Medievalists were dealing with a period for which the towering names lay in the distant past (Hippocrates, Galen) or elsewhere (Ibn Sinā). They did not entirely eliminate asides about the relative stagnation of the medical tradition they were studying. Yet they did try to see it steadily and whole, surveying the valleys as much as the peaks, and through exacting textual scholarship. A prime example is Medicine in Medieval England by Charles Talbot (1906–93), accessible and un-footnoted, yet ‘earthed’ throughout in first-hand acquaintance with manuscripts, and revising established chronologies by downplaying the distinctiveness and originality of early medical teaching in Salerno. Talbot’s chapter headings touch most of the ‘bases’ of current scholarship. Published in 1967, when medical history was supposedly only just escaping the dominance of retired physicians celebrating their great predecessors, this book can still be read with profit.15 On such foundations rests the edifice of modern scholarship. That scholarship has taken on the imposing mass of commentaries, ‘questions’, and other writings produced by the academic physicians—carrying the investigation into the belly of the beast.16 It has shown how these writings relate to their surrounding literary and philosophical culture, and how they make sense in their own terms. It can help explain why one European doctor might think it worthwhile to devote a lifetime to writing a multi-million word commentary on the entire million-word Canon of Avicenna.17 The practical dimension of scholastic medicine—as evident in the resolution of conflicts between Galen and Aristotle as in discussions of specific drugs—has been fully revealed in this newer historiography. Here, it emerges, was a tradition by no means in thrall to its big names, whether ancient or Islamic. New discoveries were quite conceivable—within the established framework of humours and complexions that would, after all, in many respects outlast the eighteenth century, let alone the Renaissance. Progress could also be made on particular fronts. In surgery, for instance, medieval techniques were refined and improved even as the vocabulary became more learned and philosophical—all of course within a setting that included neither antisepsis nor effective anaesthesia.18 The vignette of Gueraula above is one example of a more general phenomenon about which we are only just beginning to learn: the vernacularization of learned medicine during the closing centuries of the Middle Ages, both orally and through written translations into the principal European languages. That is how some itinerant healer who had picked up the rudiments of uroscopy could pass them on to Gueraula in a rural or suburban setting. Presumably for readers without competence in Latin, whether practi-

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tioners or patients, or simply for the curious, these translations made the lineaments of academic medicine appreciated far beyond the academy.19 Our best evidence for this demand may be the flourishing, within Christian Europe, of Jewish physicians, at almost every level from the cheaply retained civic doctor to the papal courtier. No legal or cultural discrimination weighed heavily against the perception that Jewish doctors—who made up a far more substantial proportion of the Jewish population than Christian healers did of theirs—had access to the same sources of learning in Arabic or Hebrew translation as their counterparts in the universities (from which Jews were, almost without exception, excluded).20 From the work done on this broad terrain inhabited by university professors, Jewish practitioners, and those benefiting from some form of vernacularized learning, it is clear that a highly mature sub-discipline of medical history has evolved and that its subject has been made intelligible within a large cultural context. How should that sub-discipline continue to develop? In one respect by studiously not developing, not moving onto new agenda, but by doing more of the same. This field will not be adequately mapped without more critical editions and studies of writings—academic, para-academic, and popular—that have often not been read attentively since 1500. However, another approach, to complement the minutiae of philological analysis, might be to attempt an aerial view of the whole, to assume a quasi-anthropological distancing. Was this ‘bad medicine’—worse than a placebo? Or is it to its credit that some of the most learned physicians acknowledged the ‘psychological’ value of what we call the placebo effect? Was this a medicine that depended for its effectiveness on its rhetoric? Is ‘effectiveness’, with its overtones of measurable results in the modern laboratory, even the right word? Should we rather think in terms of ‘success’: medicine as essentially a verbal and gestural performance that aims to leave patients ‘satisfied’—a state that may only partially resemble anything we would now recognize as improved physical health?21

Men and women at the bedside Part of the answer to these questions will have to come from the theoretical writings that are the main material deposit of all the rhetoric. But another part must surely come from adopting the patient’s perspective. We began in the university classroom. It is time to look to the sickbed. Doing so is hard. We mostly lack even the case notes of the highly educated practitioner, let alone testimony to the clinical behaviour of the illiterate healer. The scholastic physicians have, of course, left us a great deal. They wrote practica on the application of specific remedies and techniques. They published consilia, letters of advice to colleagues or distant patients. But neither takes us very far from the realms of theory. These writings are always in some degree self-promotional, designed to show scientia operativa, theory in operation, yet unencumbered by individual symptoms, diagnoses, and treatments.

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To get a little nearer to the sickbed we can sometimes turn to catalogues of experimenta—tested remedies, rather than experiments in the modern sense, but ‘experimental’ in that no one knew why they worked (despite the scholastics’ smokescreen talk of ‘specific forms’ and ‘hidden properties’). Arnald of Villanova recorded seventy-three successful ‘experimental’ treatments that he provided to named individuals in or around the papal court in Avignon between 1305 and 1311.22 Although some treatments require gems, gold, mercury, and alcohol, Arnald’s remedies are generally simple—far less exotic than those he expounded (perhaps to impress colleagues or patrons) in his theoretical works. There is even less humoral or complexional background than we might expect from the ‘experimental’ genre. And some of the ailments he addresses (in patients of both sexes) hardly seem worthy of the foremost ‘consultant’ of his time. They include haemorrhoids, wrinkles, hair loss, and fleas, as well as amnesia and toothache. If this is the nearest we can get to the clinical ‘coal face’ of a university physician then it is a poor counterbalance to the reams of scholastic teaching that still await exploration—although it does raise large questions about the relation of classroom to bedside, questions historians are far from resolving. There are also, however, some examples of more ‘ordinary’, non-university, healers recording their ideas, procedures, and cases. Take Thomas Fayreford, a country doctor with a widespread practice in Devon and Somerset in the West of England in roughly the second quarter of the fifteenth century.23 He seems to have spent some time in Oxford and could read or write as needed in Latin, ‘Anglo-Norman’ French, and ‘Middle English’, and he was familiar, if at second hand, with several major medical treatises. Yet there is no sign that he proceeded to a degree at Oxford, then still a backwater among medical faculties. Instead, he seems to have established himself as general practitioner to a wide social range, from the local baron and his wife, and some clergy of the region, to a miller and a cellarer. He also assembled a large anthology of medical texts on prognosis and of medical recipes. This includes two related kinds of writing by the man himself. The first lists over 100 cures that he achieved, with the principal symptoms in each case. Not the least of its remarkable features is that Fayreford treated men, women, and children. Sixty-three or more of his patients were male, and forty-two female—ten of the latter afflicted by ‘suffocation of the womb’. The diagnosis, essentially that the womb had wandered, placing the diaphragm under severe pressure, was almost as controversial in the Middle Ages as it has been since.24 Yet Fayreford seems to have regarded the treatment for it, restoring the womb to its proper place, as virtually his ‘signature dish’. The other kind of writing that Fayreford included in his manuscript is represented by two sets of practica, essentially commonplace books, medical and surgical, organized by affliction, with each page first given a heading and treatments then recorded underneath as they came his way. The distinction between surgery and medicine is blurred, making syrups and dealing with stomach problems for example appearing under surgery, alongside treating wounds and burns. More striking, perhaps, in view of Fayreford’s apparent intellectual roots in the world of university medicine, is, first, the variety of his sources (the wife of that local baron gave him a remedy for a type of migraine), and, secondly, his

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readiness to include charms and prayers—magical ‘experiments’.25 He records around forty-three healing charms, drawing no distinction between remedies that require ritual utterances and entirely ‘natural’ ones. (For epilepsy: ‘write a word of power, ananizapta, on parchment and wear it with a piece of mistletoe, around the neck.’) He also includes procedures that to our eyes partake of the symbolic. For rotten teeth: ‘take a green frog that leaps in trees on sacred ground, and anoint any tooth that you wish to fall out with that green substance’. That was the sort of application that the masters of the Paris medical faculty would have liked to attribute to Jacoba (or Jacqueline) Felicie when they arraigned her in 1322 for unlicensed medical practice.26 The female patients of Arnald and Thomas whom we have encountered, not to mention Thomas’s alertness to wandering wombs, should already have invalidated any notion that ‘women’s health was women’s business’—men treating men only. What could women do? Thanks to her surviving trial documents, Jacoba is probably the best-known female healer of the Middle Ages. She was not the victim of an explicitly chauvinist legal regime. Rather she was caught up in one of many attempts, which gathered pace during the later Middle Ages, to limit medical practice to the educated, and thus (supposedly) more reliable. In November 1322, along with two men as well as three other women (notably, one of them a Jew, another a Jewish convert), she was excommunicated and fined. At her trial Jacoba essayed two lines of defence. The first was that she did not belong to those ‘illiterates and air heads’ at whom the law was surely aimed. Socially, she claimed to be a cut above them: ‘the noble woman Lady Jacoba’. She claimed to know medical theory and witnesses at her trial offered consistent testimony to what sounds like the successful practice of a trained doctor (compare Gueraula’s limited repertoire). She examined pulse as well as urine, touched and palpated, prescribed and administered drugs, and contracted with her patients for a fee if she cured them. ‘I shall make you well, God willing,’ she said, ‘if you will have faith in me.’ Taddeo Alderotti or Arnald of Villanova could have used just those words. Jacoba, for her part, gained the confidence of a variety of Parisians, including ‘the Lord Odo’, a ‘brother’ of the Paris hospital, whom she visited there and at the baths, besides treating him in her own house. Jacoba’s second line of defence cut no more ice with the Paris masters. It was the ‘argument from modesty’—that a female healer could visit women and if necessary examine their ‘private parts’, whereas a man could not. In some areas of Europe this argument might have carried weight (southern Italy, for example), but Paris was not among them.27 Generally, it seems that a variety of male and female practitioners—doctors, surgeons, apothecaries, and village ‘empirics’—examined and treated both men and women with a perhaps surprising degree of impartiality. So far, we have encountered five representative individuals. There were two scholastic physicians, active in major centres of university learning (Arnald of Villanova and Taddeo Alderotti). Then came a rural ‘wise woman’ who had picked up an impressive smattering of the techniques and vocabulary that both Taddeo and Arnald used (Gueraula), then a country doctor on the penumbra of that learned world (Fayreford). Finally, there was a Parisian woman who would clearly have considered herself more

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than a match for any of the men (Jacoba). This small gallery has introduced several themes. Chief among them is self-conscious ‘professionalization’, an assertion of superiority not only by physicians but also by their would-be colleagues among the surgeons, who raised their game intellectually precisely so as to emulate the physicians’ previously achieved status. We have also noted in passing the regimes of licensing meant to underpin that status, the standing of Jewish practitioners (whose own evident learning helped meet a demand that Christians alone could not supply), and some of the various ways by which medical learning was vernacularized and thus made available to a circle of healers and patients far wider than that of the universities. In any full-length account these themes would all deserve not just elaboration but extension into related topics. For example, the emphasis in the preceding vignettes lay on disease and its remedies. But, as noted above, regimen or diet—preventive medicine—was possibly the larger domain, in terms of how learned doctors distributed their time and, even, exercised their pens. On another front, we have seen men attempting to control or curtail women’s general therapeutic activities. That raises the question of how those attempts bore specifically on gynaecology and on the production of texts such as the renowned ‘Trotula’ corpus, parts of which at least may have been written by a woman, and are seemingly unique in that respect.28

Medical theory, magic, and religion Pressing questions are also raised by the vignettes themselves. First, was there, in medieval medicine quite generally, a significant difference between theory and practice— between the elaborate therapeutics outlined under the banner of ‘complexion’ on one hand and the simple ‘theory-light’ medication actually prescribed?29 That is a topic on which progress can be made only by much further reading in manuscripts and early printed editions. Second, what was the connection between medicine and magic? That is for the most part a conceptual question. Clearly, ritualized, quasi-religious charms and amulets thread their way through both the medical literature of experimenta (to which magica was cognate) and also academic treatises. Inexplicable in the usual theoretical terms, such magical procedures could be included as last resort or as easier, cheaper alternatives. Few authors rejected them altogether, and even those who did could nonetheless concede their occasional value in reassuring the patient. What mattered more than any clear-cut distinction between scientia and magica were the questions of value and authority. Did these exceptional techniques have beneficial effects, and did the reports of their effects come from good sources? As long as they did, they might be recommended by healers and tried by patients without serious transgression.30 By way of illustration, consider the marriage of Francesco Datini, Iris Origo’s famous ‘merchant of Prato’, and his wife, Margherita.31 Their union had been barren from the start. During the early 1390s friends wrote to recommend the ‘fertility treatments’ of various types of healer. Margherita’s sister recommended a woman who made foul-

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smelling poultices for the belly. A physician friend wrote to Francesco relating his wife’s fertility to pre-menstrual pain and offering a report on proven treatments that the merchant could show to his own doctors for approval. Thirdly, Margherita’s brother-in-law, Niccolò, relayed, from her sister, a further recommendation: an amulet in the form of a belt. ‘She says,’ Niccolò wrote on his wife’s behalf, that: it is to be girded on by a boy who is still a virgin, saying first three Our Fathers and Hail Marys in honour of God and the Holy Trinity and St Catherine; and the letters written on the belt are to be placed on the belly, on the naked flesh . . . But I, Niccolò, think it would be better, in order to obtain what she wishes, if [Margherita] fed three beggars on three Fridays, and did not hearken to women’s chatter.32

Margherita’s friends and family thus between them recommended four different kinds of remedy. (Note that apparently no one, male or female, proposed any treatment for her husband.) The physician—a man accustomed to attending bishops and cardinals, as well as women in labour—represented university medicine. Not coincidentally he was the only correspondent to propose a diagnosis. The Florentine woman who made poultices was an ‘empiric’, the social equivalent of Gueraula. The amuletic belt would not have been classified as magical. It depended for its effects on the power of its written text, the oral prayers that were to accompany putting it on, and also (as we would say) the symbolic force of its being put on by a virgin boy—a boy, therefore, of maximum reproductive potential, which might presumably be transferred through the belt into the mother’s naked flesh. Finally, the brother-in-law thought it would be better to avoid ‘woman’s chatter’ (remedies that came on no good authority) and to favour not university medicine, but simple piety, as authorized by the Church Fathers. Two versions of naturalistic medicine, therefore: ‘high’ and ‘low’, learned and ‘empirical’. And two versions of ritual, both probably involving prayer, but one of them ‘magical’, the other orthodox Christian. Margherita was a wealthy woman. She could afford the most expensive medicine. Yet she was, seemingly, open to all these recommendations. Neither she nor her husband apparently found the different approaches—medical, ‘magical’, and religious—at all incompatible. The Italian vignette prompts the broader question of how medicine and religion interacted in Christian Europe. As it happens, with the possible exception of Arnald, none of the healers mentioned up to now was a priest. However, many in holy orders did practise medicine, especially in England and France. One medical writer, known as Peter of Spain, is probably to be identified with the man who became Pope John XXI (d. 1277). Popes routinely retained and consulted physicians—Jewish, as well as Christian. By the later Middle Ages, physicians were being consulted in a range of contexts where, a few centuries previously, their presence would have been surprising: for example, canonization processes, to which they were called as ‘expert witnesses’ on healing miracles.33 That related as much to the phenomenon that has been called, with some exaggeration, the ‘medicalization’ of society, as it does to the Church. However, it still shows that ecclesiastical authorities at the highest level held naturalistic medicine in high regard.

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The medieval Church never banned resorting to secular medicine by either priesthood or laity, and sought to limit the practice of medicine and surgery by those in major holy orders or in religious houses only in specific circumstances.34 A few extremists might confine themselves to a pure medicine of the soul—prayer, fasting, almsgiving, receiving the sacrament. For the majority, the accommodation that faith offered to therapy came with just one proviso: that medical practitioners retain a sense of their place in the grand scheme of things, always remembering the ultimate source of health and healing. As the fathers assembled at the Fourth Lateran Council in 1215 put it, here as in so many respects establishing the template for Latin Christendom, since ‘illness of the body’ is sometimes (not invariably) the result of sin, the confessor should take clinical precedence over the physician.35 If this regulation was more honoured in the breach, it still arose from an only lightly qualified appreciation of the capacities of secular medicine. Such medicine offered a model of authority that academic theologians, preachers, and confessors took as a ready source of convincing metaphors, starting with that of Christ as the physician of humanity. Of course Christ is superior to all worldly physicians. In one sermon by a thirteenthcentury master, Ranulphe de la Houblonnière, who became bishop of Paris, this superiority is manifested in the way Christ offers himself as a cure in his Passion.36 He undertakes a forty-day fast, swallows the bitter medicine of vinegar mixed with bile, is tied up and flogged (like a madman), submits to bloodletting on the cross, and is bathed by his own blood, washing all humanity clean. No human doctor could compete. And yet the assertion of the utter superiority of spiritual medicine, precisely through the imagery chosen as its vehicle, acknowledges the potency of secular medicine. Only such a set of ideas could adequately convey the salvific effect of Christ’s death on the cross. Master Ranulphe, as a university man himself, was, not surprisingly, developing his analogy just when university medical faculties were beginning to assert themselves. This medieval anticipation of a baroque literary conceit of course has roots almost as old as Christianity. Christus medicus was an idea elaborated by the Fathers of the Church, especially Augustine.37 Discussion of the interrelation of medicine and religion, like the other themes just reviewed, cannot be confined to the high and later Middle Ages, the twelfth to later fifteenth centuries, the world of the schools and the university medical faculties. So far, the examples offered have all been later medieval. Very often discussion begins and ends then. The world before medical schools seems alien. The medicine of the early Middle Ages in Europe, c.700–1050, is indeed relatively uncharted. Despite our ignorance of more than a few of its contours, though, it has often been found wanting. ‘If one surveys the state of medical knowledge in late antiquity and in the early Middle Ages in Western Europe, it is deplorable.’ That was written in 1984, and perhaps few would now pronounce in such terms.38 Nonetheless, derogation of the early Middle Ages, by comparison with a classical past and a later medieval future (a university future), remains implicit in even the best scholarship. It reflects the difficulties that the early Middle Ages present.

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The early Middle Ages Of the Middle Ages generally, but particularly their earliest phase, the volume of evidence for any given ‘sector’ of the therapeutic world is in inverse proportion to its relative significance for sick individuals. Hagiography provides our most abundant evidence for the ‘everyday life’ of the period, and thus for healing practices, but does not take us beyond didactic vignettes, and the miraculous healings attested in it can have benefited only the fortunate few. We know of only a small number of individual doctors. Medievalists lack the inscriptions and papyri that elucidate the lower reaches of the medical ‘profession’ in the classical world. Legal texts, charters, penitentials, and historical narratives offer only glimpses. ‘Magical’ healers are yet more obscure. Domestic healing, often, presumably, by women, must have been the most common type, but is hardly documented at all. What, then, can be said? Blandly that the early Middle Ages in Western Europe had a variety of therapeutic cultures, involving a range of healers: saints, clerics, educated lay people, magicians, ‘empirics’—and, yes, monks. And that this variety is roughly comparable to the culture of the central to later Middle Ages. The problem, once we attempt greater specificity, is that the early medieval period presents too fragmented and confusing a picture for historians to find much sense in it. Contrast the preceding and subsequent periods. Late antiquity can be summed up in terms of the slow Christianizing of the medical ‘profession’, the triumph of Galenism, and the refining of that Galenic inheritance in encyclopaedias and handbooks.39 At the other chronological end, as we have seen, the later Middle Ages are dominated by the ‘gold standard’ of university medicine. In both cases, there are some central features around which a narrative can be built. But the early Middle Ages offer no such armature. The theory, Galenic or other, has been drained out of the surviving medical texts. There were no schools, no canonical texts, and no encyclopaedic reference works. Instead, all is mutability. The over 160 medical manuscripts that survive from the period c.750–900 are each unique, and often take the form of disorderly anthologies of short writings or excerpts from longer ones. Some texts were copied in clusters, but with variations in content, arrangement, and ascribed authorship. To generalize about the manuscripts is therefore hard. There are no clear evolutions in the relative popularity of one component text over another, although the surviving manuscripts may be an oblique guide to the range of what once existed. To sample the interpretative challenges that this early medieval material presents, we can turn to a single leaf of a single manuscript. Around 800, somewhere in the Carolingian empire, a scribe faced a blank page in a large codex.40 It fell not between texts in an anthology but towards the end of Book I of the great treatise from classical antiquity by Dioscorides, De materia medica. A blank was too rare and expensive to leave, and there was no shortage of herbal remedies to fill it. Instead, our scribe copied out an epistle on vulture medicine.41 This was not veterinary matter, but the remedies to

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be derived from the body of a newly captured vulture. ‘Here begins the Letter of the Vulture’ is the heading, in not altogether standard Latin. The text is framed as a letter from the King of Rome. ‘The human race does not know how much efficacy [virtus] the vulture has in it and how much it promotes health.’ No explanation of that virtus is given. We are told only that the bird should be killed with a sharp reed within an hour of capture. Before decapitating it one should say: ‘Angelus, Adonai, Abraham, on your account the prophecy is fulfilled.’ This should be repeated when it is cut open to begin the harvest of remedies: head bones wrapped in deer skin for migraine; eyes wrapped in wolf skin for eye problems; heart in lion or wolf skin against possession; and so on. The vulture does not only promote health in these ways; it can aid social and economic well-being. Put its tongue in your right shoe and your enemies will adore you. Rub its grease into a traction animal you are selling and you will receive the asking price. There ended the list from which the scribe was copying. He wrote ‘finit finit’ to leave no doubt. Overleaf, Dioscorides resumes. Conceptual questions are immediately raised, of a kind familiar by now from the Florentine correspondence above. Is this Christianized ‘magic’ explicable in biological terms—of vultures’ perceptible ability to eat and digest carrion: in effect vacuuming up disease? Did the scribe expect use of the letter to achieve practical results? His setting is likely to have been a monastery, but is this monastic medicine? Monastic labourers might be interested in selling an animal for a good price. But what about this? ‘You dry and beat [the vulture’s] kidneys and testicles and give it with wine to the man unable to have intercourse with his wife.’ Useful medical information? For future ‘pastoral’ advice? Would it in any case have been easy to implement the recommendations, inside or outside a religious house? Vultures can be caught, as can wolves and deer, but how easily? Or is it that the mere possession of the information conferred a certain advantage? That raises the question of whether the epistle is to be taken as medicine at all or as a ‘secret of nature’, tucked away in a manuscript the size of which (over 320 folios) would make it more a work of reference than a book for any bedside. That is another way of asking the fundamental question cui bono? The manuscripts of this period, roughly the Carolingian age in Europe, can quite often be associated with particular centres of production, and in a few cases with particular patrons. Yet of no codex can we say why it was copied or for what readership. The surviving books come almost entirely from the institutions best able to preserve them: monasteries and, in the later part of the period, cathedral schools. Yet some of these books may have been intended for ‘lay’ (non-monastic and non-clerical) households or may have been copied from lay-owned exemplars. And that is as far as we can go. How close they came to the bedside can only be conjectured. We should, however, resist projecting back into the medieval past our own perplexity in the face of such material. Very little of early medieval medicine was judged so deficient that it was superseded by the philosophically oriented material of the university world. Early medieval medicine is to some extent ancient medicine (e.g. Dioscorides) continued by other means. But it is also (later) medieval medicine. In most cases the

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manuscripts of the Carolingian era were not the end of the road for the writings that they preserved. Vulture medicine continues to circulate throughout the Middle Ages, especially in the vernacular. One thirteenth-century German text affords us the crucial information that we must catch our vulture unawares. Forewarned, it may swallow its own brain.42

Conclusion: back to the future The discipline of medical history has sometimes been diagnosed as liable to a similar reaction, swallowing and regurgitating its own narrow, self-imposed agenda. Where should it go next? The principal achievements thus far of the historiography of medieval medicine have been to assess many of the main texts on their own terms, avoiding reference to biomedicine, and giving the texts first an intellectual context and then, more recently, a social one—so far as the evidence permits. What should be the agenda for coming decades? There are those who advocate conceptual ‘permanent revolution’ as the only way forward. However, instead of reading (say) more Foucault, medievalists should, as suggested above, be editing more texts. There remains a dispiriting lack of critical editions or simple reading editions, and translations, even of the major writings. This is especially true of the Latin texts of the earlier Middle Ages (those frustrating anthologies) and of the vernacular material of the later Middle Ages—which, with the exception of that in Middle English, has yet to be surveyed. In the process of reclaiming more texts, two further types of evidence need to be integrated into the larger emerging picture. Both already have historiographies of their own, but this percolates only spasmodically into the ‘main stream’. One of these types is imagery—in manuscripts or early printed books or on walls—which appears in extremely varied and complex relations to the texts. The tendency by mainstream historians has perhaps been to read the images too literally and also to adopt them simply as illustrations of what we already know from texts. A more routinely sophisticated engagement is called for, one that treats the visual evidence as a primary resource in its own right, rather than a mere supplement.43 The other type of evidence shades into that formed by illustrations: it is archaeology. Perhaps the two should be thought of together—as offering a material culture of medical history. Again, the imperative is to allow what has often been taken as ancillary to speak with an independent voice. For the high and central Middle Ages the archaeology of medical instruments is likely to remain limited, but that of medicaments—deposits of actual remedies—certainly has potential. And for the early Middle Ages, from which the evidence of practice is yet more limited, the analysis of finds of instruments, and of palaeopathological signs of surgery or orthopaedics, must be pressed for a far greater contribution to the overall picture. Palaeopathology, of which the one modern development is DNA extraction, has of course been used in a different direction, the ‘diagnosis’ of historical diseases, especially the ‘Black Death’. Its importance must grow beyond

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addressing such simplistic questions as ‘was the Black Death an epidemic of yersinia pestis or some other disease?’ to embrace all those conditions of which skeletal or biomolecular evidence can be recovered—not only malaria, for example, but physical impairment.44 In the process some major conceptual questions will have to be addressed. How do we relate the modern biology of historical diseases to contemporary (medieval) cultural understandings and representations? Is the contemporary doctor’s diagnosis (even à la malade imaginaire) the only one that historians can entertain—or is palaeopathology an admissible check to such relativism? We need, on this testing philosophical front, a local resolution of the nature/culture debate, so that medical historians can write the history of diseases without anachronism, but also without sidestepping the biological evidence.45 If we are not sure what disease is, or has been, we may feel on firmer ground in defining medicine. That sense of security may be mistaken. Or perhaps it should be made to seem mistaken. In the examples above we have met learned physicians and surgeons, and male and female magicians or empirics, who variously proposed regimens, made prognoses, and undertook courses of treatment. We have not discussed—as ideally we should—nurses, midwives, hospital orderlies, priests visiting and anointing the sick and administering the sacraments, astrologers, suppliers of drugs and cosmetics, and saints acting through their relics: the ideal table of contents is lengthy. Nor should it be confined to people. Sacred images, gardens, music, and natural sounds—these too could have an effect on the soul and thus indirectly on the body. Doctors of medicine and doctors of theology might explain the effect in different terms, but their explanations converged on a more or less single set of genuinely psychosomatic phenomena. Perhaps we need a history of therapies, or of healing, rather than a history of medicine, with emphasis on the interaction between different types. We have already seen in the cases of Thomas Fayreford and the Datini family that remedies were exchanged through correspondence networks. The resulting ‘free market’ in ideas about healing was by no means always dominated by the medical elite, despite the widespread appeal of a university-type medicine. A truly synoptic view of conceivable sources of therapy—people, artefacts, nature—would embrace correspondingly various networks of interaction. This need not involve only the patient’s perspective, much vaunted in the latertwentieth-century historiography of medicine, yet, as we have seen, very hard to recapture using medieval evidence. Giving weight to environmental therapy could for instance be one solution to an unnecessarily vexed question in the history of hospitals—were they intended for ‘care’ or ‘cure’?46 Or, to put it another way, how and when were they medicalized, in the sense of having doctors present and to some extent in control? Instead of looking only at hospital physicians, suppose we open discussion up, not only to the whole range of the hospital population, but to the whole environment of the establishment, its architecture, its material culture, its natural surroundings. A different picture of its therapeutic capacities might then emerge, against which the question of the presence or absence of doctors would seem less decisive.

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The hospital needs a still wider context, though. Indeed one approach to the history of therapy, apart from the obvious and already well-developed one of gender, comes under the heading of space. What are the spaces of the therapeutic encounter—from the university lecture room to the hospital or shrine, and how do they interrelate?47 That prompts a still larger question, also spatial. Where is medieval medicine? The Middle Ages were invented in the Renaissance to apply to Europe. The contrast between the dominant university medicine of the thirteenth to fifteenth centuries and the far less systematic medical writing of preceding centuries should not be overstated, so we saw, because the earlier material continued to be copied and used throughout. Nonetheless, university medical faculties do define a period. The contrast is real, and it more or less corresponds to the periodization that medievalists generally use. Yet we should not expect this period labelling to work elsewhere. In Byzantium, for instance, the medicine of which remains a generally neglected field, there was no break in the Galenic tradition bequeathed to the Eastern empire through medical schools such as the one at Alexandria.48 In that respect the early Middle Ages in Byzantium are not of course comparable to those in Western Europe, which lost contact with Greek learning in the sixth and seventh centuries. Most of the manuscripts on which progress in the field must depend are what a Western medievalist would call central or later medieval. In terms of the major surviving texts, it is possible to distinguish a Late Antiquity (from the fourth to early seventh centuries) of encyclopaedism: the ‘reformatting’, abbreviating, and simplifying of Galenic medicine into large manuals for ease of comprehension and use. Then there is a ‘middle’ period of some substantial compilations, still essentially summarizing the (late) antique legacy (ninth to eleventh centuries? the dating of many writers remains controversial), and finally a ‘late’ phase (after the depredations of the Latin empire, 1204–61) in which some philosophical physicians, named and securely dated individuals, take centre stage. Yet underlying this tripartite division, and to a considerable extent blurring it, is a more continuous tradition of ‘lowlevel’ iatrosophia: practical collections of remedies for ordinary but sufficiently literate rural healers and hospital attendants.49 These seem to be comparable to the miscellanies of the early Middle Ages in Europe—but many of them await proper study, and it will be some time before we have an integrated medical history of the Middle Ages that can treat East and West synoptically. Islamic medicine presents a different periodization. Its classical period is defined by the beginning of the translation movement (mainly from Greek into Arabic) in the ninth century and might end with the death of Ibn Sinā in 1037 (though slightly later figures could also be admitted to the ‘golden age’). The overall effect, whatever the dates chosen, is to esteem the earlier period over the supposedly epigonal phase (which might in its turn be said to end with full Ottoman domination of the Middle East). That is virtually the converse of the implicit valuation of Western medievalists, more at home in the university world than in the amorphous early Middle Ages. Because of the questionable value judgements implied, the supposed differences between earlier and later medieval medicine in Islam seem ripe for reappraisal.50

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There is no need to pursue ‘Middle Ages’ further East. The foundational writings of the Ayurvedic and classical Chinese traditions correspond very roughly to classical antiquity in Western terms, although the ideas and techniques are demonstrably still older than the surviving manuscripts. The major medical finds in the caves near Dun Huang can be described as representing ‘medieval Chinese medicine’ only in a very loose sense of the term.51 Yet the Dun Huang texts are associated with the transmission of ideas and remedies along the various ‘silk roads’ and thus provide a powerful reminder. They remind us that, however we label the periods in question, both the beginning of the Middle Ages (on a Western yardstick) of the sixth to eighth centuries and the high Middle Ages, of widespread Mongol rule across Asia in the thirteenth to fourteenth centuries, were periods of ‘incipient globalization’, periods in which our ‘longitudinal’ approach, staying in one area and watching one period succeed another, seems to demand replacement by a latitudinal view, in which East and West meet and interpenetrate. For example, a conceptual distinction of Tibetan medicine, itself deeply affected by Hellenistic ideas in the seventh century, can find its way to the surface again in a tenth-century Jewish text, written in Italy. If that can happen, then our geographical categories are as much in need of rethinking as our chronological ones.52

Notes 1. Nancy Siraisi, Taddeo Alderotti and His Pupils (Princeton, NJ: Princeton University Press, 1981), 237–68, 305–410; Danielle Jacquart, ‘Medical Scholasticism’, in Mirko D. Grmek (ed.), Western Medical Thought from Antiquity to the Middle Ages (Cambridge, MA/ London: Harvard University Press, 1998), 197–240. 2. Roger Bacon, ‘On the Errors of Physicians’, trans. Edward Withington, in Charles Singer and Henry E. Sigerist (eds), Essays on the History of Medicine (London: Oxford University Press; Zürich: Verlag Seldwyla, 1924), 144. 3. Nancy Siraisi, Medieval and Renaissance Medicine (Chicago/London: University of Chicago Press, 1990), 48–78. For Salerno, Monica H. Green, The ‘Trotula’: A Medieval Compendium of Women’s Medicine (Philadelphia: University of Pennsylvania Press, 2001), 3–14. 4. Katharine Park, Secrets of Women (New York: Zone Books, 2006). 5. Jerome J. Bylebyl, ‘The Medical Meaning of Physica’, Osiris, 2nd series, 6 (1990), 16–41. 6. Peter Murray Jones, ‘Complexio and experimentum: Tensions in Late Medieval Medical Practice’, in Elisabeth Hsu and Peregrine Horden (eds), The Body in Balance (Oxford: Berghahn, forthcoming). 7. Siraisi, Medieval and Renaissance Medicine, 17–47; Michael McVaugh, Medicine before the Plague: Practitioners and Their Patients in the Crown of Aragon, 1285–1345 (Cambridge: Cambridge University Press, 1993), 108–35. 8. Siraisi, Taddeo Alderotti, 277. 9. Marilyn Nicoud, Les régimes de santé au Moyen Âge, 2 vols (Rome: École française de Rome, 2007). 10. Luke Demaitre, ‘The Art and Science of Prognostication in Early University Medicine’, Bulletin of the History of Medicine 77 (2003), 765–88.

medieval medicine 11. 12. 13. 14.

15. 16.

17. 18. 19.

20. 21.

22. 23.

24. 25. 26. 27. 28. 29. 30.

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McVaugh, Medicine before the Plague, 139–42. Siraisi, Taddeo Alderotti, 282. McVaugh, Medicine before the Plague, 2–3. Gert Brieger, ‘The Historiography of Medicine’, in W. F. Bynum and Roy Porter (eds), Companion Encyclopedia of the History of Medicine (London and New York: Routledge, 1993), vol. 1, 24–44; Frank Huisman and John Harley Warner (eds), Locating Medical History: The Stories and their Meanings (Baltimore, MD, and London: Johns Hopkins University Press, 2004). C. H. Talbot, Medicine in Medieval England (London: Oldbourne, 1967). Danielle Jacquart, La médecine médiévale dans le cadre Parisien XIVe–XVe siècle (Paris: Fayard, 1998); Joseph Ziegler, ‘Ut dicunt medici: Medical Knowledge and Theological Debates in the Second Half of the Thirteenth Century’, Bulletin of the History of Medicine 73 (1999), 208–37. Roger French, Canonical Medicine: Gentile da Foligno and Scholasticism (Leiden: Brill, 2001). Michael McVaugh, The Rational Surgery of the Middle Ages (Florence: SISMEL, Edizioni del Galluzzo, 2006). The Middle English corpus has been the most fully surveyed. See the electronic revised version of Linda Ehrsam Voigts and Patricia Deery Kurtz, Scientific and Medical Writings in Old and Middle English (2000), accessible via the databases link on the Medieval Academy of America’s home page; also Irma Taavitsainen and Päivi Pahta (eds), Medical and Scientific Writing in Late Medieval English (Cambridge: Cambridge University Press, 2004). For one theme in the vernaculars, see Monica H. Green, Making Women’s Medicine Masculine: The Rise of Male Authority in Pre-Modern Gynaecology (Oxford: Oxford University Press, 2008), Ch. 4. Joseph Shatzmiller, Jews, Medicine, and Medieval Society (Berkeley: University of California Press, 1994). Elisabeth Hsu, ‘Medical Anthropology, Material Culture, and New Directions in Medical Archaeology’, in Patricia Anne Baker and Gillian Carr (eds), Practitioners, Practices and Patients: New Approaches to Medical Archaeology and Anthropology (Oxford: Oxbow, 2002), 1–15. Michael McVaugh, ‘The Experimenta of Arnald of Villanova’, Journal of Medieval and Renaissance Studies 1 (1971), 107–18. Peter Murray Jones, ‘Thomas Fayreford: An English Fifteenth-Century Medical Practitioner’, in Roger French et al. (eds), Medicine from the Black Death to the French Disease (Aldershot: Ashgate, 1998), 156–83. Green, ‘Trotula’, 22–34; Helen King, Hippocrates’ Woman (London: Routledge, 1998), Ch. 11. Lea T. Olsan, ‘Charms and Prayers in Medieval Medical Theory and Practice’, Social History of Medicine 16 (2003), 343–66. Monica H. Green, ‘Conversing with the Minority: Relations among Christian, Jewish, and Muslim Women in the High Middle Ages’, Journal of Medieval History 34 (2008), 105–18, at 108. Green, Making Women’s Medicine Masculine, 113–14. Green, ‘Trotula’. McVaugh, ‘Experimenta’, 111; compare Emilie Savage-Smith, ‘The Practice of Surgery in Islamic Lands: Myth and Reality’, Social History of Medicine 13 (2000), 307–21. McVaugh, ‘The “Experienced-Based Medicine” of the Thirteenth Century’, Early Science and Medicine 14 (2009), 105–30, at 123–4.

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31. Katharine Park, ‘Medicine and Magic: The Healing Arts’, in Judith C. Brown and Robert C. Davis (eds), Gender and Society in Renaissance Italy (Harlow: Longman, 1998), 129–49. 32. Iris Origo, The Merchant of Prato (London: Jonathan Cape, 1957), 161. 33. Joseph Ziegler, ‘Practitioners and Saints: Medical Men in Canonization Processes in the Thirteenth to Fifteenth Centuries’, Social History of Medicine 12 (1999), 191–225. 34. Darrel W. Amundsen, Medicine, Society and Faith in the Ancient and Medieval Worlds (Baltimore: Johns Hopkins University Press, 1996), Ch. 8. 35. Canon 22, in Norman P. Tanner (ed.), Decrees of the Ecumenical Councils, 2 vols (London: Sheed and Ward, 1990), 1: 245–6. 36. Joseph Ziegler, Medicine and Religion c.1300: The Case of Arnau de Vilanova (Oxford: Oxford University Press, 1998), 186. 37. Rudolph Arbesmann, ‘The Concept of Christus Medicus in St. Augustine’, Traditio 10 (1954), 1–28. 38. Gerhard Baader, ‘Early Medieval Latin Adaptations of Byzantine Medicine in Western Europe’, Dumbarton Oaks Papers 38 (1984), 251–9, at p. 251. 39. Vivian Nutton, Ancient Medicine (London/New York: Routledge, 2004), Ch. 19. 40. Augusto Beccaria, I codici di medicina del periodo presalernitano (Rome: Edizioni di Storia e Letteratura, 1956), 157–9. 41. Loren C. MacKinney, ‘An Unpublished Treatise on Medicine and Magic from the Age of Charlemagne’, Speculum 18 (1943), 494–6. 42. Francis B. Brévart, ‘Between Medicine, Magic and Religion: Wonder Drugs in German Medico-Pharmaceutical Treatises of the Thirteenth to Sixteenth Centuries’, Speculum 83 (2008), 1–57, at p. 40. 43. See Jean A. Givens et al. (eds), Visualizing Medieval Medicine and Natural History, 1200– 1550 (Aldershot: Ashgate, 2006). 44. Vivian Nutton (ed.), Pestilential Complexities: Understanding Medieval Plague (London: Wellcome Trust Centre for the History of Medicine at UCL, 2008). 45. Andrew Cunningham, ‘Identifying Disease in the Past: Cutting the Gordian Knot’, Asclepio 54 (2002), 13–34. 46. Peregrine Horden, ‘A Non-Natural Environment: Medicine without Doctors and the Medieval European Hospital’, in Barbara S. Bowers (ed.), The Medieval Hospital and Medical Practice (Aldershot: Ashgate, 2007), 133–45. 47. Patricia Anne Baker et al. (eds), Medicine and Space: Body, Surroundings, and Borders in Antiquity and the Middle Ages (Leiden: Brill, 2011). 48. Symposium on Byzantine Medicine, Dumbarton Oaks Papers 38 (1984). 49. Barbara Zipser (ed.), John the Physician’s ‘Therapeutics’: A Medieval Handbook in Vernacular Greek (Leiden: Brill, 2009). 50. Peter E. Pormann and Emilie Savage-Smith (eds), Medieval Islamic Medicine (Edinburgh: Edinburgh University Press, 2007), Ch. 2; N. Peter Joosse and Peter E. Pormann, ‘Decline and Decadence in Iraq and Syria after the Age of Avicenna? ‘Abd al-Latif al-Baghdadi (1162–1231) between Myth and History’, Bulletin of the History of Medicine 84 (2010), 1–29. 51. Vivienne Lo and Christopher Cullen (eds), Medieval Chinese Medicine: The Dunhuang Medical Manuscripts (London/New York: Routledge, 2005). 52. Forthcoming work by Ronit Yoeli-Tlalim. See also Asian Medicine 13, 2 (2008).

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Select Bibliography Bjork, Robert E. (ed.), The Oxford Dictionary of the Middle Ages, 4 vols (Oxford: Oxford University Press, 2010), ‘Medicine’. Green, Monica H., ‘Integrative Medicine: Incorporating Medicine and Health into the Canon of Medieval European History’, History Compass 7 (2009), available at http:// compass.bw.semcs.net/subject/history. ——, Making Women’s Medicine Masculine: The Rise of Male Authority in Pre-Modern Gynaecology (Oxford: Oxford University Press, 2008). Grmek, Mirko D. (ed.), Western Medical thought from Antiquity to the Middle Ages (Cambridge, MA/London: Harvard University Press, 1998). Horden, Peregrine, ‘Sickness and Healing’, in T. F. X. Noble and Julia M. H. Smith (eds), Early Medieval Christianities, c.600–c.1100 (Cambridge: Cambridge University Press, 2008), 416–32. —— , ‘What’s Wrong with Early Medieval Medicine?’, Social History of Medicine 24 (2011), 5–25. McVaugh, Michael, Medicine before the Plague: Practitioners and their Patients in the Crown of Aragon, 1285–1345 (Cambridge: Cambridge University Press, 1993). Rawcliffe, Carole, Medicine and Society in Later Medieval England (Stroud: Allan Sutton, 1995). Siraisi, Nancy, Medieval and Renaissance Medicine (Chicago/London: University of Chicago Press, 1990). Wallis, Faith (ed.), Medieval Medicine: A Reader (Toronto: University of Toronto Press, 2010).

chapter 4

e a r ly moder n m edici n e t homas rütten

Early modern medicine describes medicine, in chronological terms, between the fourteenth and seventeenth centuries. General historiography considers the medieval period to have ended around 1500 and the early modern period to have begun around 1450. The choice of an earlier onset of the early modern period here (c.1350), which corresponds to Italian historiographic traditions, is motivated by a Europe-wide perspective on early modern medicine. It was in Italy that the autumn of the Middle Ages already loomed in the fourteenth century, presaging an early spring for the modern era, which needs to be taken into consideration when trying to understand the continuity of medieval medicine-related social structures, institutions, ideas, and practices beyond more recent thresholds of the early modern epoch.1 Topographically, early modern medicine not only spans the medicine of Europe and the ‘New World’, but also incorporates the various multifaceted forms of non-European medicine, such as Chinese medicine, Ayurvedic and Unani medicine, and Peruvian medicine, which came increasingly into reciprocal contact with Western medicine during this period.2 In this chapter, I will focus on so-called Western medicine, which, in the form of learned medicine, represented one of the three higher faculties (alongside theology and law) and was taught from Coimbra to Dorpat and from Messina to Uppsala on the basis of a certain canon of Greek and Arabic texts in Latin translations. Especially in Italy, doctors had to undergo training in philosophy before embarking on their medical training.3 Both learned and popular medicine were represented by an ‘extraordinary range of individuals who wandered across Europe as an effect of war, religious divisions, economic pressures, and intellectual curiosity’.4 The early modern community of health care providers was well networked across denominational, geographic, and linguistic borders, thanks to a shared lingua franca (Latin), a common historical heritage, and comparable social structures, as well as apparatuses of State and Church power. Even those health care providers with insufficient Latin necessarily participated in the Latin-language discourse, to which the vernacular

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medical literature was in fact substantially obliged. It is, however, noteworthy that only 30 to 40 per cent of the male and 10 per cent of the female population were literate at all. Hippocratic–Galenic medicine not only affected the conventional operations of medical training at universities, but it had also penetrated deep into folk medicinal practice. Next to Hippocrates (c.460–c.375 bce) and Galen (129-c.210 ce), Plato (428/7–349/8 bce) and Aristotle (384–322 bce), Pliny the Elder (23/4–79 ce) and Dioscorides (fl. around 50 ce), Aetius (sixth century ce) and Paul of Aegina (seventh century ce), Celsus (first century ce) was possibly the most significant medically relevant ancient author.5 The relationship between the Church and medicine in the early modern era was complex, particularly in the tense period of the Reformation (1517–55/60) and the CounterReformation (1555/60–1689), with its denominational strife (the French wars of religion, 1562–98; the struggle for independence in the Netherlands, as well as the Thirty Years War, 1618–48) and entrenched confessional hostilities between Catholics and Jews, Lutherans and Calvinists, Phillipists and Gnesio-Lutherans, Remonstrants and CounterRemonstrants, and Catholic missionaries (Jesuits, Dominicans, and Franciscans) in the Americas, East-Indies, Japan, and China, in addition to Protestants (Puritans) in North America. Nonetheless, the power apparatus of the Catholic Church, which shaped medicine to no small degree during this era, can be legitimately condensed to the tripartite formula, ‘Inquisition, Index, and Indoctrination’.6 In diachronic terms, one can also recognize leitmotifs in early modern medicine, some of which will be introduced below. These create a degree of spatiotemporal coherence in the field, permitting the enumeration of some characteristics of early modern Western medicine, even though, generally speaking, the greatest caution is advisable with respect to generalizations. Thus, early modern Western medicine is characterized by the unearthing, appropriation, and reworking of older traditions of medicine, classical (Galen and Hippocrates above all) and medieval (Avicenna, d. 1037; Averroës, d. 1198) alike. It was shaped by the impact of Renaissance humanism, a renewed emphasis on linguistic skills reorienting Latin towards ancient models (Ciceronian, for example)7 and channelling Greek, the language of the prisca medicina, as well as Hebrew lore (Christian Hebraism; Cabala) into Western discourse. As a sect of high literates, the humanists emphasized the correlation between, and the moralizing properties of, correct speaking, writing, and thinking, and sought to achieve with rhetoric a new incarnation as truer—more truly human—beings (homines humani). Such an agenda appealed to physicians throughout the early modern period. It surely had its practical implications, resulting in a fuller and better understanding of past medical experience and in a more precise identification of plants and drugs. However, it also held the promise of enhanced status and career advancement: rhetorical skills were considered useful in a setting that usually involved more people than just the patient and the physician; they could be instrumental in building trust among the populace and in securing patronage. Above all they became a criterion of distinction compared with non-humanist health care providers and an effective instrument of regulating the profession.

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Early modern medicine—‘Western’ will be omitted for the remainder of the chapter—is furthermore characterized by new disciplinary settings, which interlinked medicine, natural history, and alchemy: a higher faculty (medicine) with an emerging new scientific community pursuing the early modern equivalent of ‘big science’ (natural history) and a field of enquiry that was officially unwelcomed at universities but flourished at courts (alchemy).8 Thus, early modern medicine is distinguished by an increasing degree of complexity. It became further intertwined with disciplines such as astrology, alchemy, philosophy, history, and antiquarianism,9 providing flexible career paths to physicians, both in practice and in academia, as well as more choices to patients. Such enhanced complexity called for new ways of absorbing, disseminating, censoring, storing, and representing medical knowledge. The emergence of print culture, commonplace books, dictionaries, indices of forbidden books, book fairs, private and ‘public’ libraries, the growing importance of pictorial representations, and changes in note-taking techniques created ever new forms to produce, diffuse, and consume medical knowledge or censor its dissemination. Another feature of early modern medicine was its deep embeddedness in a variety of contemporary contexts, in addition to the religious one: the institutional context comprises courts, universities, academies, religious orders, towns, hospitals; the social ranges from physicians’ occupations as itinerant, town, court, and irregular physicians to other health care providers such as midwives, apothecaries, barbersurgeons, charlatans and to different fractions of the population (urban versus rural, literate versus illiterate, indigenous versus foreign). Furthermore, there is a geographical and environmental or climatic context, by which early modern medicine is shaped. Sociologically, patronage and contracts between doctors and patients are essential in early modern medicine, as is an analogy between society (and its ruler) and the human body (and its doctor). Technological advances in refining glassgrinding, metal processing, and the construction of measuring apparatuses have an immediate effect on the efficacy of visual aids, the construction of surgical instruments and the feasibility of physiological experiments. Cultural practices, ranging from the way of living (sex res non naturales) to gender roles, from giving birth to dying, from experiencing pain and impairment to instrumentalizing music and theatre for therapeutic purposes, complete the panorama of contexts that are constitutive of early modern medicine. Moreover, early modern medicine became increasingly integrated in a Republic of Letters created by doctors and intelligencers such as Nicolas-Claude Fabri de Peiresc (1580–1637), Marin Mersenne (1588–1648), Athanasius Kircher (1602–80), Samuel Hartlib (d. 1662), Martin Lister (c.1638–1712), Gottfried Wilhelm Leibniz (1646–1716), and others.10 Through its interdigitization with the new science (scientia nova) it acquired a more experiential (Francis Bacon, 1561–1626) and more mathematized (Galileo Galilei, 1564–1642) nature. Iatrochemistry and iatromechanism emerged from (and, to a certain extent, merged with) such endeavours. Medicine also remained impregnated with philosophical discourse, especially in the areas of epistemology, natural philosophy, moral philosophy, and logic.

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On the whole, however, early modern medicine is defined by such a plurality—overwhelming to the individual researcher—that it seems necessary to differentiate carefully in terms of protagonist (who), point in time (when), location (where), sequence of events (how), and motivation (why), in answering fundamental historiographical questions. Paracelsus (1493–1541), the anti-Galenist and anti-Aristotelian,11 saw the ars medica differently than his contemporary, Thomas Linacre (c.1460–1524).12 Jacobus Sylvius (Jacques Dubois, 1478–1555)13 came to conclusions fundamentally different from those of his former student Andreas Vesalius (1514–64) about discrepancies between Galenic anatomy texts and autoptic findings from the human corpse itself. And the ordinary workday of the surgeon Leonardo Fioravanti (1517/18–88), who concocted distilled drugs in a Venetian pharmacy,14 looked different from that of the municipal physician of Delft, the ‘Dutch Hippocrates’ Pieter van Foreest (1522–97).15 Although they all belonged, or claimed to belong, to a stratum of university-educated doctors and to that extent could have constituted a collective professional group (which was, in any case, a minority amidst the larger group of non-university-educated health care providers), they were anything but homogeneous. The social profiles of this group’s members, how they each received and reconfigured medical tradition, their positioning in the throng of conflicting medical concepts, institutions, and alliances—and their theological and philosophical underpinnings—and finally their self-presentation on the health care market were all strikingly different. At this temporal axis from 1350 to 1700, the world changed and medicine changed with it: it could hardly have remained the same, as the world was transformed by the Reformation and the confessional wars, by the introduction of printing, the Inquisition, the Copernican Revolution, and witch trials. Anti-Aristotelianism and anti-Galenism, neo-Platonism, scepticism, and atomism all convulsed the roots of medical philosophy,16 while colonization, missionary activity, and the globalizing of medicine’s networks extended its geographical horizon (on sickness, plants, and remedies),17 and the telescope and microscope expanded medicine’s perceptual horizon. Baconian empiricism and Cartesianism changed medicine’s methodology and proof procedures. At the same time, hermeticism, Paracelsianism, chymiatry, and iatromechanics eroded its homogeneity. In addition to the medieval hubs of knowledge (lecture halls, libraries, and dynastic courts) many new settings emerged, including the noble court,18 the anatomical theatre,19 the market place, the artisanal workshop, the botanical garden,20 the museum,21 the academy (for example, the Accademia dei Lincei),22 and the laboratory. Some would add the coffeehouse and, towards the end of the seventeenth century, the salon. Each of these sharpened and limited the observer’s perspective on nature and, correspondingly, on the nature of the human body. Each of these spaces produced its own conventions for generating, documenting, and communicating knowledge. In each, one finds various occupational profiles: from the savant to the dilettante, from the ordinary breadwinner to the ingenious polymath and virtuoso, for whom medicine was just one of many useful arts and sciences.23 The history of early modern medicine is further complicated by an imposing diversity of methodological approaches and by growing caution about unsubstantiated generalizations.

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Methodological approaches The past century of exploration into early modern medicine has been determined by an ‘extension of the historical agenda’, which, according to Paul Veyne,24 has dictated the various methodological approaches that have held their ground in the research landscape up to the present day. Biographical studies have been devoted to putative key players in the historical process, such as Marsilio Santasofia (c.1338–1405), Paracelsus, Andreas Vesalius (1573– 1654/5), and William Harvey (1578–1657).25 Such studies contribute more to our understanding of early modern medicine, the more their authors place the central medical figure in a broad context in terms of an intellectual biography, avoiding too narrow a personal focus, and capture what for medicine are constitutive dimensions, namely those of the patient and society. Today, prosopographical studies are frequently devoted to collectives, a survey of which makes the application of quantitative methods possible.26 Such studies are not always directed towards the upper echelon of physicians, who dominated the medical discourse through publications and the health care market through membership in regulatory bodies. Rather, these prosopographical studies have called attention to the broad mass of health care providers on record, who have if anything a greater claim, when measured by contact hours with patients, to be counted as representatives of early modern medicine, even if they never distinguished themselves as authors, collectors, virtuosi, or otherwise. The unpublished Biographical Index of Medical Practitioners in London and East Anglia, which informs Margaret Pelling’s Medical Conflicts in Early Modern London, focuses on the lower orders of practitioners and includes an individual ‘if he or she was apparently recognized by contemporaries as seriously engaged in the practice of physic, surgery, or midwifery’,27 in an attempt to overcome a representation of medical practitioners biased in favour of the academically qualified physician. While studies in the history of ideas have been dedicated to transformations in early modern concepts of health, illness, hygiene, dietetics, and naturalness,28 the history of ideas has also tackled the fundamental meaning of Platonic (via Plotinus, 204/5–270, and Marsilio Ficino, 1433–99) and Aristotelian philosophy as well as their infusion into Galenism, so central to the early modern understanding of the human body, its diseases, and modes of recovery.29 Achievements in institutional history have propelled into view the early modern history of hospitals,30 medical appointments,31 physicians’ guilds and associations (for example, the Royal College of Physicians of London),32 and universities.33 Likewise the history of legal institutions has been occupied with the gradual codification of medical law, including forensic autopsy, caesarean section motivated by the law of succession, and rudimentary medical law in the context of the Constitutiones Criminales.34 Studies in reception history have been applied to the epochal reception of ancient culture that all but defined medicine in the early modern period. Insofar as it was based

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on texts, that culture—transformed via the three steps of imitatio, aemulatio, and superatio35—was injected into the Latin- and later Greek-language scholarly discourse, and was conveyed another step further in its reception into the vernacular and into contemporary practice across a huge geographic area.36 On the one hand, such studies have documented the triumphs of Galenism, which humanist physicians regarded as an attempt to integrate the Hippocratic, Platonic, and Aristotelian legacies, personified as the first violinist of a contemporary string quartet, and represented visually.37 On the other hand, this work has chronicled the emancipation of Hippocratism from Galenism. Hippocrates survived this period as an identification figure for progressive-minded early modern doctors and natural historians, while Galen’s market value sank as Vesalius demonstrated Galen’s numerous errors and recalled to his contemporaries that Galen’s notions of internal anatomy were based not on human dissection but on the dissection of animals; it sank further when William Harvey discovered blood circulation and published his findings in 1628, which only led Galenic physiology ad absurdum, after his findings printed on paper of low quality in Frankfurt amidst the Thirty Years War had been received by the medical world with some delay. In addition, the continuity of medieval medicine, underexposed by contemporary rhetoric relative to the renaissance of ancient medicine, has been extensively studied (as far as texts of Latin, Persian-Arabic,38 and Jewish provenance, institutions such as hospitals, universities, and guilds, and medical practices such as urinoscopy or phlebotomy are concerned) in the 400 years between Petrarch (1304–74)39 and medical Cartesianism,40 between the Black Death (peaking between 1348 and 1350) and the early Enlightenment.41 Approaches from the perspective of social history have steered early modern research towards structures (within the Church, the state, and society) and processes (professionalization, regulation, medicalization) and developed—as well as qualitatively and quantitatively evaluated—relevant, often serial, source material.42 Social historically oriented work in medical history has opened up a panoramic view on the rich variety of medical occupations and social profiles to be found in early modern Europe, especially among ‘irregular practitioners’. This work has examined the role of other health care providers, such as barber-surgeons, apothecaries, midwives, distillers, chemists, druggists, and charlatans, and those practitioners’ struggles for a footing in the by no means unregulated medical marketplace, itself determined by supply and demand.43 Social-historical work has revealed collective phenomena within one middling group, that of ‘irregular practitioners’, which is distinguished by middle-class ideology, identification with the court, detachment from active political life, and isolation from civic responsibilities.44 As the common denominator of a broader methodological approach, the history of everyday life can be described as experiential micro-history that aims to reinstate the individual in historiography. It has depicted early modern everyday life for those with identifiable diseases and those held to be sick—among them children, women, and men, lunatics and handicapped, pregnant women and suicides, homosexuals,45 and wounded veterans. It has thus brought attention to the manifold forms in which physicians, patients, and societies defined, contested, and lived the medicine of their time.46 Thus a new history of events in early modern medicine has come into being, less about

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structures than about ‘little events’, less about institutionally administered power (through State and Church) than about power informally exercised and experienced between individuals, about the vantage point from below and the representativeness of case studies.47 Work on local and regional history takes into account that geographical coordinates are of vital importance in reconstructing early modern medicine, since only they can supply specific data on the period’s general intellectual, governmental, legal, religious, and social conditions as they pertained to medicine. Magisterial studies in national history of early modern medicine are noteworthy in this context.48 On a smaller geographical scale, early modern university medical centres have been subject to examination, such as Padua, Bologna, Ferrara, Pisa, Basel, Montpellier, Paris, Leiden, Valencia, and Salamanca, as well as other centres that stimulated the development of early modern medicine,49 and indeed the many courts at which physicians played no insignificant role. Impressive monographs have recently been dedicated to court doctors such as Theodore de Mayerne (1573–1654/5), who was active at the court of Henry IV (1553–1610) in France and later at the courts of James I (1566–1625) and Charles I (1600–1649) in England, and to their patients.50 Diachronic studies on medicine at one or more European courts have appeared,51 and conferences on early modern court medicine indicate the vitality of this field of research. Correspondingly focused works have implied a certain antagonism between court and university medicine. The increasing attraction of court medicine lies in part in the fact that it offers an ideal terrain for the study of how medicine and politics interlocked: court physicians were entrusted with ambassadorial missions; and horoscopes and astrological predictions could be instrumentalized for political ends. Also appealing to researchers is that cutting-edge, often unorthodox, medical thought and practice (such as alchemy and astrology at Italian courts and Paracelsianism at German courts) prevailed in many European courts, due to the court physician’s relative freedom from the medical orthodoxy imposed upon his royal patient’s subjects and due to a genuine interest in academic exchange on the ruler’s part. Cases in point are Federico da Montefeltro (1422–82) and his physician, Paul of Middelburg (1445–1533);52 Maximilian I (1459–1519) and Ferdinand I (1503–64) and Georg Tannstetter (1482–1535);53 Augustus, Elector of Saxony (1526–86), and Caspar Peucer (1525–1602);54 Charles VIII (1470–98), Louis XII of France (1462–1515), and Duke Antoine of Lorraine (1489–1544) and Symphorien Champier (1472–c.1535);55 Galeazzo Maria Sforza (1444–76) and Raffaele Vimercati;56 Nicolò III d’Este (1383–1441) and Leonello d’Este (1407–59) and Michele Savonarola (1385–1478);57 Rudolf II (1552–1612) and Martin Ruland the Elder (1532–1602).58 Cultural history has deepened our understanding of mores and practices, such as laughing, dreaming, degustation, feeling, sexual intercourse, habitation, and work. It has also helped to reconstruct the medical discourses that legitimized, disciplined, and perpetuated these practices during the early modern period.59 From this perspective, medicine seems to have been an integral component of culture, beliefs, perceptions, and practices characteristic of a specific group of people. The early modern practice of dissection also belongs in this context, as it was becoming a constant of the cultural life of the

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city. From the middle of the sixteenth century it took place in anatomical theatres built for that purpose.60 Performances—including not only dissected cadavers but also virtual stage-sets of skeletons and other anatomical paraphernalia—attracted a mixed audience of doctors, artists, theologians, and other interested citizens. By combining together in one person the relevant book learning with the corresponding manual dexterity of a prosector and demonstrator, the early modern anatomy professor—Vesalius embodies the type—achieved the reunification of handicraft and intellect before the very eyes of the spectator. Vesalius and those in his footsteps levelled theoretical medicine and surgical medicine—the long-term educational objective of human dissection—and balanced readings from the books of authorities (above all Galen) with readings from the book of nature.61 At the same time, the cultural community present at such events celebrated the restoration of the order of things that had been violated by the crimes of the executed: this occurred as the dissection of a human being made explicit the expediency of Creation, visible in the human physique, and derived the moral-religious purpose of mankind directly, as it were, from the (Galenic) teleology of man’s organs. New cultural practices emerged from the autoptic examination of medicinal plants, systematically cultivated in the botanical gardens that came into being in numerous cities, from Messina to Uppsala and from Valencia to Leipzig, after the opening of the orto botanico in Padua in 1545.62 As in anatomy, there was the potentially life-threatening difficulty here of bringing res and verba into congruence, of assigning the intended natural phenomena (bodily parts or plants) to the right terms encountered in the authoritative texts, and in the long term of succeeding in assembling a nomenclature that once and for all codified such correspondencies. While plants were initially collocated according to their medicinal value and seen in symbolic terms, they were subsequently organized by species—with botany becoming increasingly independent as a field—and were viewed in scientific and commercial terms. Like anatomical theatres, botanical gardens constituted artificial places in which nature, wherever in the world it was found, was condensed and staged for observational, instructional, and research purposes, but also for visitors’ natural-theological edification. Gardens as well as anatomical theatres became breeding grounds for an empiricism, which was initially meant to verify and optimize book learning, but, in the seventeenth century, most notably under the influence of Bacon, increasingly assumed the character of a stock-taking exercise that, as a team effort, operated inductively and proclaimed nature to be the highest authority.63 The history of the body has illuminated the sexualization, medicalization, and juridicization of the human body in the early modern era. Studies have shown the body of this period to be in transit: between heaven and hell (the persecution of witches);64 between home and abroad (colonization, epidemiological vectors, changes in climate); between guilt and atonement (corporeal punishment of suicide victims,65 dissection of executed criminals); and between human- and animal-kind (lycanthropy).66 This historiography has identified the early modern body as a means of expressing defined social, religious, and ideological positions, as a medical figure of thought and trove of metaphors in the discourse on statehood and denomination. Research on the early modern body maintains an intimate relationship to—and indeed sometimes merges with—the

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examination of early modern anatomy as well as the allegorization, juridicization, theatricalization, and sexualization of the human body in representations of autopsy and human dissection.67 The history of the body has not only focused on the dead body, but also highlighted the living body.68 It is interconnected with the field of visual culture, in which the role of the visual, its social function, and its significance are considered. This visual turn to images and their perception, to visualizing technologies, and to viewers’ responses has been followed by an auditory turn that concentrates on the early modern manner of experiencing sound and music and its effects on the human body.69 Finally, from a methodological perspective, women’s studies, gender studies, and gender behavioural studies have contrasted the cruder forms of biologizing and ontologizing the feminine (or masculine, as the case may be) with differentiated societal models of constructing sexuality. This has directed attention towards the female protagonists of historical events (female patients, female health care providers, female patrons) and underscored the necessity of a female-oriented historiography, not least in the field of early modern medicine, and for revisions of gendered narratives.70 That this approach has led to a radical revision of early modern medical historiography is not surprising in light of the fact that, at least up to the middle of the twentieth century, historical studies of medicine were almost exclusively written by men, for men, and about men.71

Source material All of these methodological approaches are to be found in the distinguished work done in the past four decades on early modern medicine. They have helped to discover and analyse a rich variety of source material testifying to the colourfulness of the early modern medical marketplace. To begin with, there is an enormous body of manuscripts that comprise contemporary texts along with pre-early modern texts.72 The manuscripts of Hippocratic and Galenic texts were among the latter, and their discovery, identification, collating, and editing became an essential part of Renaissance medicine, defined as it was by progressive optimism and reform-mindedness.73 In the case of Greek manuscripts, book hunters transported them during the fourteenth and fifteenth centuries in great quantities from the East to Italy, where they were copied and further dispersed.74 The discovery of such manuscripts by highly literate humanists, among whom there were initially few doctors, raised the question of the reliability, authenticity, and integrity of the Latin Hippocrates and Galen already established in the West. Greek and Hebrew studies following the Erasmian paradigm seemed to be in order for physicians as well, and set a process in motion that peaked around 1530 with the Hellenization of Renaissance medicine by physicians such as Wilhelm Copp (1460–1532), Janus Cornarius (c.1500–58), and John Caius (1510–73).75 The manuscript material is additionally interesting on account of the many traces left by readers in this primary material in the form of marginalia and interlinear glosses.76

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Through these, the manuscripts were intertextually linked to other texts and recontextualized in the contemporary literature. To this handwritten source material belong, further, enormous and sometimes untouched archival inventories of doctors’ personal files, construction plans for hospitals, records from medical litigation, correspondence, casebooks,77 compilations of material, still-unpublished treatises, prescriptions, and drawings. Examination by social historians of, in particular, probate accounts,78 parish and municipal records, apprenticeship disputes, tax records, ecclesiastical visitations, and records of ecclesiastical licensing, and the scrutiny by economic historians of rate books, has led to a more differentiated picture of the early modern health care market.79 Since the middle of the fifteenth century, when printing was introduced in the West, the numerous manuscripts consorted with a profusion of printed matter that streamed onto the Europe-wide book market, growing ever larger until the Thirty Years War. As much as printing really amounts to a media revolution,80 accompanied on the one hand by euphoric progressive optimism and on the other by conservative visions of doom, it in no way spells the end of the manuscript era. By making knowledge in general and medical knowledge in particular more quickly and more efficiently available, the introduction of printing in Europe led to an almost paradoxical increase in handwritten materials. Examples of this come in the form of handwritten traces in printed works, such as proof of possession, marginalia, marking and underlining, and amendments, but also in the form of archived manuscript material, which reflects new requirements— developing with the flourishing book market—for the organization and appropriation of knowledge. And many new manuscripts were produced as preliminary versions of printed works.81 Among the variety of textual genres relevant to medicine, which were representative in early modern printing, are textbooks and didactic poems,82 lectures and lecture notes, commentaries, consilia,83 observationes,84 problemata, dictionaries, invectives, dissertations and disputations, epistolary collections, declamatory speeches, books of secrets,85 and monographs on specific questions, as well as sermons, collections of legal cases, encyclopaedias, and fictional texts. There was an entire arsenal of genre varieties for the early modern author addressing medical questions, which permitted him (and it would nearly always be a man) to choose whichever genre he saw fit to reach his target group, to enhance chances for distribution, to ensure the intended impact, and to reconcile the publication aims with the conventions dictated by the chosen genre. Philologies (Greek, Latin, or Hebrew studies), paleology, and the study of codices and of archives are indispensable as auxiliary historiographical disciplines for the historian of early modern medicine. In addition to a multitude of books, broadsheets played a significant role in medicine for around 200 years starting from the end of the fifteenth century.86 With their combination of iconic symbols and verbal communication, their affordability, their rate of dissemination, and their origins at the publishing centres of the time (Basel, Strasbourg, Augsburg, Nuremberg, Frankfurt am Main), broadsheets and fugitive sheets typify important forms of image-based publicity with medicine-specific practical and applied modalities. It has in fact become clear that medical historians of the early modern period

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are indispensably aided by the history of books, printing, publishing, and libraries, as well as by the study of watermarks. The past two decades have likewise sharpened the historian’s gaze towards the materiality of printed matter and its location within libraries,87 and towards the uniqueness of each copy of a given edition as well as its peculiar reception history. A new focus has also developed on the paratextual elements of books such as the binding, the manufacture of which was sometimes handled by the publisher or bookseller but sometimes left to the invention of the buyer. Valuable information is thus passed on, via the binding, to today’s researcher about what significance the original buyer attributed to his purchase and where on the map of knowledge he positioned this book. Also well examined by research is the role played by book agents who acted at the behest of princes, popes, patricians, and academics, in addition to the role of book fairs, the book trade, censorship, pirated editions, and plagiarism. Broadsheets open the door to pictorial sources, which first appeared in the form of woodcuts in manuscripts, later as woodcuts, copperplate engravings, or etchings in printed material. Also among the pictorial source material available to scholars of early modern medicine are oil paintings, portraits, caricatures, drawings with medically relevant themes and representations, all of whose proper appraisal and interpretation in the context of early modern medicine and its historiography requires the art historian’s expert knowledge.88 Finally, the vast realm of material culture cannot go unmentioned. Early modern material pertinent to the history of medicine ranges here from osseous findings and exhumed human remains to machines and cabinets of curiosity,89 in which the world— including medicine—is represented figuratively as well as tangibly in miniature. Here the auxiliary sciences for research in early modern medicine extend from osteoarchaeology to the study of medical instruments.90 Also components of material culture are natural history collections that came into being from the middle of the sixteenth century on the initiative of Italian patricians. They used the humanists’ turn to nature,91 and their widening geographical horizon as an opportunity to collect the marvels of nature and to anchor those collections in courts, monasteries, and scholarly societies.

Conclusion The history of (early modern) medicine is a genuinely international and interdisciplinary enterprise, in which any given topic qualifies one ‘discipline’ (and language) to be primary and others to be ‘auxiliary’ to the research on that aspect of the field. Given the broad spectrum of potential themes, almost any combination from the pool of relevant skills, methodologies, and discipline-oriented states of the art is conceivable. Rather than religiously subscribing to disciplinary affiliations, early modernists are well advised to conceptualize and contextualize their themes broadly in terms of methodology and source types, thereby transcending the comfort zone of their home

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discipline, in which they were trained and socialized. Conflicts of competence (between historians and physicians, for example) are as unhelpful as doctrinal insistence on one methodological approach as the golden standard (for instance, social history). Such ideologically suspect discourses fail to do justice to the plurality and complexity of the issues at hand. It will be interesting, for example, to see how the examination of physical evidence (human bones, teeth, and so on) from early modern times, by way of gene-technological and palaeomicrobiological methods, will further complement, challenge, or even revolutionize our historiography of infectious diseases, epidemics, nutrition, stress, and trauma in early modern times, a historiography that so far has primarily been based on documentary evidence. And it will surely be interesting to see how the scientific communities—divided by their focuses on different source material, by their institutional affiliations, and by their skills and methods—will communicate their results to each other and negotiate and contest the new historiography of these themes. It will come as a surprise to many early modernists to see what scholars of Hippocrates and Galen can still add to our knowledge of the impact that these ancient authorities had on—and throughout—early modern medicine. Entries on Hippocrates and Galen in the Catalogus translationum et commentariorum, amounting to monographs rather than chapters, would be an important step in this direction, as would be inventories and analyses of printed books, plays, songs, poems, and imagery presenting their medical heritage to early modern audiences. The ubiquitous presence of Hippocrates and Galen in early modern medicine and culture at large is not to be underestimated. Obviously, scholars of ancient medicine have something to contribute to early modern studies in terms of the transmission and appropriation of medical texts, palaeographical and codicological studies of medical manuscripts produced in the early modern period, and the so-called recentiores, and in terms of making available the bulk of early modern medical literature in Latin and Greek to a scholarly community with diminishing proficiency of these languages. However, their work must be complemented by contributions from a wide range of disciplines other than classics, or classical scholarship, that help to highlight the many reinventions of both Hippocrates and Galen. It will also be crucial in the future to merge the scientific discourse on ‘elite’, nonvernacular medicine with the scientific discourse on ‘non-elite’ medicine represented by household medicine, folk medicine, lay practitioners, and medical consumerism. There is still an insufficient sense of a shared language of interpretation between the two communities researching either ‘elite’ or ‘non-elite’ early modern medicine. Similarly, the doctor’s perspective needs to be complemented by, not played off against, the patient’s perspective and vice versa, the female’s by the male’s, the court’s by the street’s, and so on. To achieve this, and despite all the politically motivated calls to tackle ‘big questions’, we need to produce many more individual case studies employing thick description and broad contextualization. They will highlight the nature, meaning, and function of medicine’s inevitable embeddedness in religious, legal, social, cultural, and ‘scientific’ early modern contexts and provide eminent teaching material.

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One cannot emphasize strongly enough the importance of text editions, with or without translations, of early modern texts. The exemplary work that has been done on texts such as Marsilio Ficino’s De vita triplici, Jean Fernel’s On the Hidden Causes of Things, Girolamo Mercuriale’s De arte gymnastica, or Robert Burton’s Anatomy of Melancholy has had a decisive effect on international scholarship of early modern medicine. However, the vast majority of early modern texts pertinent to the history of medicine remains unedited to this day, a state of affairs that is in urgent need of change. Critical editions of medical texts produced or reworked during the early modern period will remain the backbone of future scholarship in this field. The biggest historiographical challenge for the future, in my view, still stems from a concept that analytical philosophy of history, linguistics and semiotics, and literary criticism and reader response theory have helped to develop over the past four decades: the concept of narrative. In its turn, historical theory’s deliberations on the relations between history and text have gradually reawakened our awareness of the fact that this relationship marks an original problem in both historical thought and historiography. The history of our thinking and talking about, as well as the history of our writing of, history coincides to no small degree with the history of our pondering the relationship between text and history, language and (historical) reality. To what extent can we really read a work of historical scholarship, which is, by necessity, a linguistic artefact and product of the creative imagination, as a methodologically sound, critically validated, theoretically aware, and rationally verifiable representation of chronologically ordered and causally linked historical facts? What, if any, relationship may such a work entertain with the realm of fiction? From some perspectives, historians of early modern medicine are supposedly narrators, story-tellers, and as such, imaginative writers. In the future, such insight may have more liberating effects on the historiography of early modern medicine and release the full potential of historical imagination that has often until now been kept on a short leash by conventions, essentialist views of objectivity, and faithful beliefs in master narratives. Conversely, it may also accord authors of fiction more visibility as chroniclers of historical facts and rather accurate diagnosticians of the medicine they studied, experienced as patients, or encountered in their environment. Can novels qualify as important source material for historiography on early modern medicine? Finally, it is to be hoped that one day the history of early modern medicine will be perceived—also institutionally—as a sub-discipline of an emancipated history of medicine rather than a sub-discipline of history, or medicine, or science.

Acknowledgements I thank Nancy Siraisi, Christoph Lüthy, Jon Arrizabalaga, and Mark Jackson for reading a draft of this article and for their invaluable suggestions. I am also very grateful to all of them and Margaret Bell for ‘polishing’ my English.

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Notes 1. Ilja Micek, ‘Die Frühe Neuzeit: Definitionsprobleme, Methodendiskussion, Forschungstendenzen’, in Nada Boskovska Leimgruber (ed.), Die Frühe Neuzeit in der Geschichtswissenschaft: Forschungstendenzen und Forschungserträge (Paderborn: Schöningh, 1997), 17–38. 2. Harold J. Cook, Matters of Exchange. Commerce, Medicine, and Science in the Dutch Golden Age (New Haven, CT/London: Yale University Press, 2007); Nancy G. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago: University of Chicago Press, 1990); Andrew Wear, ‘Medicine in Early Modern Europe, 1500–1700’, in Lawrence I. Conrad, Michael Neve, Vivian Nutton, Roy Porter, and Andrew Wear (eds), The Western Medical Tradition 800 bc to ad 1800 (Cambridge/New York: Cambridge University Press, 1995), 215–70. 3. Hiro Hirai, Medical Humanism and Natural Philosophy: Renaissance Debates on Matter, Life and the Soul (Leiden: Brill, forthcoming). 4. Margaret Pelling, Medical Conflicts in Early Modern London: Patronage, Physicians, and Irregular Practitioners 1550–1640 (Oxford: Clarendon Press, 2003), 9; Ole Peter Grell, Andrew Cunningham, and Jon Arrizabalaga (eds), Centres of Medical Excellence?: Medical Travel and Education in Europe, 1500–1789 (Farnham, UK/Burlington, VT: Ashgate, 2010). 5. Pedro Conde Parrado, Hipócrates latino: El De Medicina de Cornelio Celso en el Renacimiento (Valladolid: Secretariado de Publicaciones e Intercambio Editorial, Universidad de Valladolid, 2003). The most revealing instrument to measure Galen’s influence on Renaissance medicine is Richard J. Durling, ‘A Chronological Census of Renaissance Editions and Translations of Galen’, Journal of the Warburg and Courtauld Institute 24 (1961), 230–305. 6. Ole Peter Grell and Andrew Cunningham (eds), Medicine and the Reformation (London: Routledge, 1993); eidem (eds), Religio medici: Medicine and Religion in Seventeenth-Century England (Aldershot: Scolar Press, 1998); Luis García Ballester, Los moriscos y la medicina: Un capítulo de la medicina y la ciencia marginadas en la España del siglo XVI (Barcelona: Labor, 1984); John M. Effron, Medicine and the German Jews: A History (New Haven, CT: Yale University Press, 2001); David B. Ruderman, Jewish Thought and Scientific Discovery in Early Modern Europe (Detroit: Wayne State University Press, 2001). 7. Woulter Bracke and Herwig Deumens (eds), Medical Latin: From the Late Middle Ages to the Eighteenth Century (Brussels: Koninklijke Academie voor Geneeskunde van België, 2000). 8. Bruce Moran, The Alchemical World of the German Court: Occult Philosophy and Chemical Medicine in the Circle of Moritz of Hessen, 1572–1632 (Stuttgart: Franz Steiner, 1991); William R. Newman, Secrets of Nature: Astrology and Alchemy in Early Modern Europe (Cambridge, MA: MIT Press, 2001); William R. Newman, Promethean Ambitions: Alchemy and the Quest to Perfect Nature (Chicago: Chicago University Press, 2005); Lawrence M. Principe (ed.), Chymists and Chymistry: Studies in the History of Alchemy and Early Modern Chemistry (Sagamore Beach, MA: Science History, 2007); Didier Kahn, Alchimie et paracelsisme à la fin de la Renaissance (1567–1625) (Genève: Droz, 2007). 9. Nancy G. Siraisi, History, Medicine, and the Traditions of Renaissance Learning (Ann Arbor: University of Michigan Press, 2008). 10. Ian Maclean, ‘The Medical Republic of Letters before the Thirty Years War’, Intellectual History Review 18 (2008), 15–30.

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11. Ole Peter Grell (ed.), Paracelsus: The Man and His Reputation, His Ideas and Their Transformation (Leiden/Boston/Cologne: Brill 1998); Charles Webster, Paracelsus: Medicine, Magic and Mission at the End of Time (New Haven, CT: Yale University Press, 2008). 12. Francis Maddison, Margaret Pelling, and Charles Webster (eds), Essays on the Life and Work of Thomas Linacre, c. 1460–1524 (Oxford: Clarendon Press, 1977). 13. Gerhard Baader, ‘Jacques Dubois as a practitioner’, in Andrew Wear, Roger K. French, and Iain M. Lonie (eds), The Medical Renaissance of the Sixteenth Century (Cambridge: Cambridge University Press, 1985), 146–54. 14. William Eamon, The Professor of Secrets: Mystery, Medicine, and Alchemy in Renaissance Italy (National Geographic, 2010). 15. Henriette A. Bosman-Jelgersma (ed.), Pieter van Foreest: de Hollandse Hippocrates (Krommenie: Knijnenberg, 1996); Henriette A. Bosman-Jelgersma et al. (eds), Petrus Forestus Medicus (Amsterdam: Stichting, 1996). 16. James Hankins, Plato in the Italian Renaissance (Leiden: Brill, 1994); Alessandro Pastore (ed.), Girolamo Fracastoro fra medicina, filosofia e scienze della natura (Florence: Olschki, 2006); Concetta Pennuto, Simpatia, fantasia e contagio: il pensiero medico e il pensiero filosofico di Girolamo Fracastoro (Rome: Ed. di Storia e Letteratura, 2008); Alessandro Roccasalva, Girolamo Fracastoro: astronomo, medico e poeta nella cultura del Cinquecento italiano (Genova: Nova Scripta Ed., 2008); Richard H. Popkin and Charles B. Schmitt (eds), Scepticism from the Renaissance to the Enlightenment (Wiesbaden: Harrassowitz, 1987); Kurd Lasswitz, Geschichte der Atomistik vom Mittelalter bis Newton, 2 vols (Hamburg/Leipzig: L. Voss, 1890); Andrew Pyle, Atomism and Its Critics: Problem Areas Associated with the Development of the Atomic Theory of Matter from Democritus to Newton (Bristol: Thoemmes, 1997); William R. Newman, Atoms and Alchemy: Chymistry and the Experimental Origins of the Scientific Revolution (Chicago: University of Chicago Press, 2006). 17. Brian W. Ogilvie, The Science of Describing: Natural History in Renaissance Europe (Chicago: Chicago University Press, 2006); José M. López-Piñero, ‘The Pomar Codex (ca. 1590): Plants and Animals of the Old World and from the Hernandez Expedition to America’, Nuncius 7 (1992), 35–52; Patricia Vöttiner-Pletz, Lignum Sanctum: zur therapeutischen Verwendung des Guajak vom 16. bis zum 20. Jahrhundert (Frankfurt am Main: Govi, 1990). 18. Moran, Patronage and Institution. 19. Gottfried Richter, Das anatomische Theater (Berlin: Ebering, 1936). 20. John Prest, The Garden of Eden: The Botanical Garden and the Re-creation of Paradise (New Haven, CT: Yale University Press, 1981); Karen Reeds, Botany in Medieval and Renaissance Universities (New York: Garland, 1991). 21. Paula Findlen, Possessing Nature: Museums, Collecting, and Scientific Culture in Early Modern Italy (Berkeley: University of California Press, 1994). 22. Vincenzo Pirro (ed.), Federico Cesi e i primi Lincei in Umbria (Arrone: Thyrus, 2005). 23. Cases in point are the physicians Martin Lister and John Evelyn. See Anna Marie Roos, The Salt of the Earth: Natural Philosophy, Medicine, and Chymistry in England, 1650–1750 (Leiden and Boston: Brill, 2007); Gillian Darley, John Evelyn: Living for Ingenuity (New Haven, CT/London: Yale University Press, 2006). 24. Paul Veyne, Comment on écrit l’histoire (Paris: Éditions du Seuil, 1978), 140–56. Quoted from Ian Maclean, Logic, signs and nature in the Renaissance. The case of learned medicine (Cambridge: Cambridge University Press, 2002), 3.

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25. Karl Sudhoff, Paracelsus: Ein deutsches Lebensbild aus den Tagen der Renaissance (Leipzig: Bibliographisches Institut, 1936); Charles D. O’Malley, Andreas Vesalius of Brussels: 1514– 1564 (Berkeley: University of California Press, 1964); Geoffrey Keynes, The Life of William Harvey (Oxford: Clarendon Press, 1966); Tiziana Pesenti, Marsilio Santasofia tra corti e università: La carriera di un monarcha medicinae del Trecento (Treviso: Antilia, 2003). 26. Andrea Cristiani, I lettori di Medicina allo Studio di Bologna nei secoli XV e XVI (Bologna: Analisi Trend, 1987); Francesco Raspadori, I maestri di medicina ed arti dell’ Università di Ferrara 1391–1950 (Florence: Olschki, 1991). 27. Pelling, Medical Conflicts in Early Modern London, 344. 28. Klaus Bergdolt, Wellbeing: A Cultural History of Healthy Living, trans. Jane Dewhurst (Cambridge: Polity, 2008); Jon Arrizabalaga, John Henderson, and Roger K. French, The Great Pox: The French Disease in Renaissance Europe (New Haven, CT/London: Yale University Press, 1997); Luke Demaitre, Leprosy in Premodern Medicine: A Malady of the Whole Body (Baltimore: Johns Hopkins University Press, 2007); Nancy G. Siraisi, ‘Disease and Symptom as Problematic Concepts in Renaissance Medicine’, in Eckhard Kessler and Ian Maclean (eds), Res et verba in the Renaissance (Wiesbaden: Harrassowitz, 2002), 217–40; Heikki Mikkeli, Hygiene in the Early Modern Medical Tradition (Helsinki: Acad. Scientiarum Fennica, 1999). 29. Teodoro Katinis, Medicina e filosofia in Marsilio Ficino: il Consilio contro la pestilenza (Rome: Ed. di Storia e Letteratura, 2007); Charles Lohr, Latin Aristotle Commentaries, vol. 2: Renaissance Authors (Florence: Olschki, 1988); Charles Schmitt, ‘Aristotle among the Physicians’, in Wear et al., The Medical Renaissance of the Sixteenth Century, 1–15; Owsei Temkin, Galenism: Rise and Decline of a Medical Philosophy (Ithaca: Cornell University Press, 1973). 30. John Henderson, The Renaissance Hospital: Healing the Body and Healing the Soul (New Haven, CT/London: Yale University Press, 2006). 31. David Gentilcore, Healers and Healing in Early Modern Italy (Manchester: Manchester University Press, 1998); Andrew W. Russell (ed.), The Town and State Physician in Europe from the Middle Ages to the Enlightenment (Wiesbaden: Harrassowitz, 1981); John Tate Lanning, The Royal Protomedicato: The Regulation of the Medical Profession in the Spanish Empire (Durham, NC: Duke University Press, 1985); María Luz López Terrada and Àlvar Martínez Vidal (eds), ‘El Tribunal del Real Protomedicato en la Monarquía Hispánica’, Dynamis 16 (1996), 17–259. 32. George Clark, A History of The Royal College of Physicians of London, 2 vols (Oxford: Clarendon Press, 1964); Harold J. Cook, The Decline of the Old Medical Regime in Stuart London (Ithaca: Cornell University Press, 1986). 33. Nancy G. Siraisi, Medicine and the Italian Universities, 1250–1600 (Leiden/Boston: Brill, 2001); Maclean, Logic, Signs and Nature in the Renaissance; Hilde D. Ridder-Symoens, A History of the University in Europe, vol. 2: Universities in Early Modern Europe (1500–1800) (Cambridge: Cambridge University Press, 1996). 34. Monica Green and Daniel Lord Smail, ‘The Trial of Floreta d’Ays (1403): Jews, Christians, and Obstetrics in Later Medieval Marseille’, Journal of Medieval History 34 (2008), 185–211; Silvia de Renzi, ‘Witnesses of the Body: Medico-legal Cases in Seventeenth-Century Rome’, Studies in History and Philosophy of Science 33 (2002), 219–42; Jonathan Seitz, ‘ “The Root is Hidden and the Material Uncertain”: The Challenges of Prosecuting Witchcraft in Early Modern Venice’, Renaissance Quarterly 62 (2009), 102–33; Cathy McClive, ‘Blood

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and Expertise: The Trials of the Female Medical Expert in the Ancien-Régime Courtroom’, Bulletin of the History of Medicine 82 (2008), 86–108. 35. Consider the ‘error’ literature produced in the wake of Leoniceno’s attack on Pliny by doctors such as Symphorien Champier, Giovanni Manardo (1461–1536), Leonhart Fuchs (1501–66), and Girolamo Cardano. 36. Anthony Grafton, Glenn W. Most, and Salvatore Settis (eds), The Classical Tradition (Cambridge, MA: Harvard University Press, 2010). 37. See the woodcut of Symphorien Champier, Symphonia Platonis cum Aristotele et Galeni cum Hippocrate (Paris: Badius, 1516). On Champier, see Brian P. Copenhaver, Symphorien Champier and the Reception of the Occultist Tradition in Renaissance France (The Hague/ Paris/New York: Mouton, 1978). 38. Nancy G. Siraisi, Avicenna in Renaissance Italy: The Canon and Medical Teaching in Italian Universities after 1500 (Princeton: Princeton University Press, 1987). 39. See Monica Berté, Vincenzo Fera, and Tiziana Pesenti (eds), Petrarca e la Medicina (Messina: Centro Interdipartimentale di Studi Umanistica, 2006); Klaus Bergdolt, Arzt, Krankheit und Therapie bei Petrarca: die Kritik der Medizin und Naturwissenschaft im italienischen Frühhumanismus (Weinheim: VCH, Acta Humaniora, 1992). 40. Gerrit Lindeboom, Descartes and Medicine (Amsterdam: Rodopi, 1978); Franco Trevisani, Descartes in Germania (Milano: Angeli, 1992); Vincent Aucante, La philosophie médicale de Descartes (Paris: Presses universitaires de France, 2006). 41. An example of a phenomenon bridging medieval and early modern medicine is the Articella: Jon Arrizabalaga, ‘The Death of a Medieval Text: The Articella and the Early Press’, in Roger French et al. (eds), Medicine from the Black Death to the French Disease (Aldershot: Ashgate, 1998), 184–220; Jon Arrizabalaga, The Articella in the Early Press c. 1476–1534 (Cambridge: Wellcome Unit for the History of Medicine; Barcelona: Department of History of Science, 1998). 42. Andrew Cunningham and Ole Peter Grell (eds), Health Care and Poor Relief in Protestant Europe, 1500–1700 (London: Routledge, 1997); Ole Peter Grell, Andrew Cunningham, and Jon Arrizabalaga (eds), Health Care and Poor Relief in Counter-Reformation Europe (London: Routledge, 1999). 43. Pelling, Medical Conflicts in Early Modern London; Doreen Evenden, The Midwives of Seventeenth-Century London (Cambridge/New York: Cambridge University Press, 2000); Hilary Marland, The Art of Midwifery: Early Modern Midwives in Europe (London: Routledge, 1993); David Gentilcore, Medical Charlatanism in Early Modern Italy (Oxford: Oxford University Press, 2006); Teresa Huguet-Termes, Jon Arrizabalaga, and Harold J. Cook (eds), Health and Medicine in Hapsburg Spain: Agents, Practices, Representations (London: Wellcome Trust Centre for the History of Medicine at UCL, 2009). 44. In this context, studies from economic history, devoted for example to drug imports, ought to be mentioned: Patrick Wallis, ‘Consumption, Retailing, and Medicine in Early-Modern London’, Economic History Review 61 (2008) 26–53; Pamela H. Smith and Paula Findlen (eds), Merchants and Marvels: Commerce and the Representation of Nature in Early Modern Europe (New York: Routledge, 2002). 45. Helmut Puff, Sodomy in Reformation Germany and Switzerland 1400–1600 (Chicago: University of Chicago Press, 2003). 46. See, for example, H. C. Erik Midelfort, A History of Madness in Sixteenth-Century Germany (Stanford: Stanford University Press, 1999).

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47. Thomas Rütten, ‘Masquerades with the Dead: The Laughing Democritus in an Observatio on Melancholy by Pieter van Foreest’, in Yasmin Haskell (ed.), Diseases of the Imagination and Imaginary Disease in the Early Modern Period (Turnhout: Brepols, in press), 227–54. 48. Laurence Brockliss and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997); Andrew Wear, Knowledge and Practice in English Medicine, 1550– 1680 (Cambridge: Cambridge University Press, 2000); Luis García Ballester, La búsqueda de la salud: sanadores y enfermos en la España medieval (Barcelona: Península, 2001). 49. Jerome J. Bylebyl, ‘The School of Padua: Humanistic Medicine in the Sixteenth Century’, in Charles Webster (ed.), Health, Medicine and Mortality in the Sixteenth Century (Cambridge: Cambridge University Press, 1979), 335–70; Gianna Pomata, Contracting a Cure: Patients, Healers, and the Law in Early Modern Bologna (Baltimore/London: Johns Hopkins University Press, 1998); Vivian Nutton, ‘The Rise of Medical Humanism: Ferrara: 1464–1555’, Renaissance Studies 11 (1997), 2–19; Patrizia Castelli (ed.), ‘In supreme dignitatis . . .’ Per la storia dell’Università di Ferrara 1391–1991 (Florence: Olschki, 1995); Mario Dal Tacca, Storia della medicina nello studio generale di Pisa dal 14° al 20° secolo (Pisa: Primula, 2000); Albrecht Burckhardt, Geschichte der medizinischen Fakultät zu Basel (Basel: Friedrich Reinhardt, 1917); Louis Dulieu, La Médecine à Montpellier, II: La Renaissance (Avignon: Presses universelles, 1979); Danielle Jacquart, La Médecine médievale dans le cadre parisien, XIVe–XVe siècle (Paris: Fayard, 1998); Françoise Lehoux, Le Cadre de vie des médecins parisiens aux XVIe et XVIIe siècles (Paris: Picard, 1976); Cook, Matters of Exchange; Jonathan Israel, The Dutch Republic: Its Rise, Greatness, and Fall, 1477–1806 (Oxford: Clarendon Press, 1998); Teresa Santamaría Hernández, El humanismo médico en la Universidad de Valencia (Siglo XVI) (Valencia: Consell Valencià de Cultura, 2003); Jesús Pérez Ibáñez, El humanismo médico del siglo XVI en la Universidad de Salamanca (Valladolid: Secretariado de Publicaciones e Intercambio Científico, Universidad de Valladolid, 1997); Katharine Park, Doctors and Medicine in Early Renaissance Florence (Princeton: Princeton University Press, 1985); Claudia Stein, Die Behandlung der Franzosenkrankheit in der Frühen Neuzeit am Beispiel Augsburgs (Stuttgart: Steiner, 2003). 50. Hugh R. Trevor-Roper, Europe’s Physician: The Various Life of Sir Theodore de Mayerne (Yale: Yale University Press, 2006); Stanis Perez, La santé de Louis XIV: Une biohistoire du Roi-soleil (Seyssel: Champ Vallon, 2007). 51. Alexandre Lunel, La Maison médicale du roi. XVIe–XVIIIe siècles (Paris, 2008); Vivian Nutton (ed.), Medicine at the Courts of Europe, 1500–1837 (London/New York: Routledge, 1990). 52. Dirk Jan Struik, ‘Paul van Middelburg (1445–1533)’, Mededeelingen van het Nederlandsch Historisch Instituut te Rome 5 (1925), 79–118. 53. Franz Stuhlhofer, ‘Georg Tannstetter, Astronom und Astrologe bei Maximilian I. und Ferdinand I.’, Jahrbuch des Vereins für Geschichte der Stadt Wien 37 (1981), 7–49. 54. Claudia Brosseder, Im Bann der Sterne: Caspar Peucer, Philipp Melanchthon und andere Wittenberger Astrologen (Berlin: Akademie Verlag, 2004). 55. Copenhaver, Symphorien Champier. 56. Monica Azzolini, ‘The Politics of Prognostication’, History of Universities 23 (2008), 6–34. 57. Chiara Crisciani, ‘Michele Savonarola, medico tra università e corte, tra latino e volgare’, in Nadia Bray (ed.), Filosofia in volgare nel medioevo. Atti del convegno della Società italiana per lo studio del pensiero medievale, Lecce, 27–29 settembre 2002 (Louvain-la-Neuve: Fédération Internationale des Instituts d’Études Médiévales, 2003), 433–49.

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58. Robert John Weston Evans, Rudolf II and His World: A Study in Intellectual History, 1576– 1612 (Oxford: Clarendon Press, 1973); Steven vanden Broecke, The Limits of Influence: Pico, Louvain, and the Crisis of Renaissance Astrology (Leiden: Brill, 2003). 59. See, for example, Heli Tissari, Anne B. Pessi, and Mikko Salmela (eds), Happiness, Cognition, Experience, Language (Helsinki: Helsinki Collegium for Advanced Studies, 2008); Quentin Skinner, Visions of Politics, 3 vols (Cambridge: Cambridge University Press, 2002), vol. 3. 60. Paula Findlen, ‘Anatomy Theatres, Botanical Gardens, and Natural History Collections’, in Katherine Park and Lorraine Daston (eds), The Cambridge History of Science, vol. 3: Early Modern Science (Cambridge: Cambridge University Press, 2006), 277; Andrea Carlino, Books of the Body: Anatomical Ritual and Renaissance Learning, trans. John Tedeschi and Anne C. Tedeschi (Chicago: Chicago University Press, 1999); Giovanna Ferrari, L’ esperienza del passato: Alessandro Benedetto filologo e medico umanista (Florence: Leo S. Olschki, 1996); Andrew Cunningham, The Anatomical Renaissance: The Resurrection of the Anatomical Projects of the Ancients (Brookfield: Scolar, 1997); Katharine Park, Secrets of Women: Gender, Generation, and the Origins of Human Dissection (New York: Zone Books, 2006). 61. Allen G. Debus and Michael T. Walton (eds), Reading the Book of Nature: The Other Side of the Scientific Revolution (Kirksville, MO: Sixteenth Century Journal Publications, 1998). 62. Nicholas Jardine, James A. Secord, and Emma C. Spary (eds), Cultures of Natural History (Cambridge: Cambridge University Press, 1996); Findlen, ‘Anatomy Theatres, Botanical Gardens, and Natural History Collections’, 282; Margherita Azzi Visentini, L’Orto botanico di Padova e il giardino del Rinascimento (Milan: Edizioni il Polifilo, 1984). 63. Gianna Pomata and Nancy G. Siraisi (eds), Historia: Empiricism and Erudition in Early Modern Europe (Cambridge, MA: MIT Press, 2005). 64. Richard M. Golden (ed.), Encyclopedia of Witchcraft: The Western Tradition (Santa Barbara, CA: ABC-CLIO, 2006); Stuart Clark, Thinking with Demons: The Idea of Witchcraft in Early Modern Europe (Oxford: Clarendon Press, 1997). 65. Lieven Vandekerckhove, On Punishment: The Confrontation of Suicide in Old-Europe (Leuven: Leuven University Press, 2000); Michael MacDonald and Terence R. Murphy, Sleepless Souls: Suicide in Early Modern England (Oxford: Clarendon Press, 1990). 66. Caroline Oates, ‘Metamorphosis and Lycanthropy in Franche-Comté, 1521–1643’, in Michel Feher et al. (eds), Fragments for a History of the Human Body, Part one (New York: Zone, 1989), 305–63; Walter Stephens, Demon Lovers, Witchcraft, Sex, and the Crisis of Belief (Chicago/London: University of Chicago Press, 2002); Erica Fudge (ed.), Renaissance Beast: Of Animals, Humans, and Other Wonderful Creatures (Urbana: University of Illinois Press, 2004); Erica Fudge, Brutal Reasoning: Animals, Rationality, and Humanity in Early Modern England (Ithaca: Cornell University Press, 2006); Brett D. Hirsch, ‘Lycanthropy in Early Modern England: The Case of John Webster’s The Duchess of Malfi’, in Haskell (ed.), Diseases of the Imagination (in press). 67. Park, Secrets of Women; Bette Talvacchia, Taking Positions: On the Erotic in Renaissance Culture (Princeton: Princeton University Press, 1999), 161–87; David Hillman and Carla Mazzio, The Body in Parts: Fantasies of Corporeality in Early Modern Europe (New York/ London: Routledge, 1997); Jonathan Sawday, The Body Emblazoned: Dissection and the Human Body in Renaissance Culture (London: Routledge, 1995).

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68. Michael Stolberg, Homo patiens: Krankheits- und Körpererfahrung in der Frühen Neuzeit (Köln: Böhlau, 2003). 69. David Garrioch, ‘Sounds of the City: The Soundscape of Early Modern European Towns’, Urban History 30 (2003), 5–25. 70. Monica H. Green, Making Women’s Medicine Masculine: The Rise of Male Authority in Premodern Gynaecology (Oxford: Oxford University Press, 2008); Susan Broomhall, Women’s Medical Work in Early Modern France (Manchester: Manchester University Press, 2004); Juliana Schiesari, The Gendering of Melancholia: Feminism, Psychoanalysis, and the Symbolics of Loss in Renaissance Literature (Ithaca/London: Cornell University Press, 1992); Doreen Evenden, The Midwives of Seventeenth-Century London (Cambridge: Cambridge University Press, 2000); Lynette Hunter and Sarah Hutton (eds), Women, Science and Medicine 1500–1700 (Stroud: Sutton, 1997). 71. The exception to this rule is at best Elseluise Haberling (1888–1945): Henry Wahlig, ‘Elseluise Haberling’, in Hiram Kümper (ed.), Historikerinnen: Eine biobibliographische Spurensuche im deutschen Sprachraum (Kassel: Stiftung Archiv der Deutschen Frauenbewegung, 2009), 98–9. 72. For handwritten material, see, for example, the approximately 1,200 medicine-related pages of Leibniz’s papers at the Niedersächsische Landesbibliothek of Hanover, not to mention Leibniz’s various correspondences with physicians. See also the Clusius project conducted in Leiden (approximately 1,300 letters exchanged between Carolus Clusius, 1526–1609, and approximately 300 correspondents), as well as the numerous letters of Theodor Zwinger (1533–88) kept in Basel and currently part of a research project conducted at Würzburg University and entitled ‘Frühneuzeitliche Ärztebriefe’. 73. Pearl Kibre, Hippocrates Latinus: Repertorium of Hippocratic Writings in the Latin Middle Ages, rev. edn (New York: Fordham University Press, 1985). For Greek manuscripts of Hippocratic and Galenic works, see Hermann A. Diels, Die Handschriften der griechischen Ärzte. Unveränderter fotomechanischer Nachdruck [der Ausgabe von Berlin] 1905–1907 (Leipzig: Zentralantiquariat der DDR, 1970); Robert E. Sinkewicz, Manuscript Listings for the Authors of Classical and Late Antiquity (Toronto/Ontario: Pontifical Institute of Medieval Studies, 1990). 74. Remigio Sabbadini, Le Scoperte di Codici Latini e Greci ne’ Secoli XIV e XV, Edizione anastatica con nuove aggiunte e correzioni dell’ autore a cura di Eugenio Garin (Florence: Sansoni Editore, 1967); Nigel G. Wilson, From Byzantium to Italy: Greek Studies in the Italian Renaissance (London: Duckworth, 1992); Robert R. Bolgar, The Classical Heritage and Its Beneficiaries: From the Carolingian Age to the End of the Renaissance (Cambridge: Cambridge University Press, 1958); Robert R. Bolgar, Classical Influences on European Culture a.d. 1500–1700 (Cambridge: Cambridge University Press, 1976). 75. Vivian Nutton, ‘Hellenism Postponed: Some Aspects of Renaissance Medicine, 1490–1530’, Sudhoffs Archiv 81 (1997), 158–70; Stefania Fortuna, ‘Wilhelm Kopp possessore dei Par. gr. 2254 e 2255? Ricerche sulla sua traduzione del De victus ratione in morbis acutis di Ippocrate’, Medicina nei secoli arte e scienza 13 (2001), 47–57; Marie-Laure Monfort, L’apport de Janus Cornarius (ca. 1500–1558) à l’édition et à la traduction de la collection hippocratique, Thèse de doctorat, Université de Paris-Sorbonne, 1998; Vivian Nutton, John Caius and the Manuscripts of Galen (Cambridge: Philological Society, 1987). 76. Danielle Jacquart, Scientia in margine: Études sur les marginalia dans les manuscrits scientifiques du Moyen Âge à la Renaissance (Genève: Librairie Droz, 2005).

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77. For example, the astrologers Simon Forman’s and Richard Napier’s casebooks encoded in an astrological system and recording more than 50,000 consultations between 1596 and 1634 held in the Bodleian Library: Alfred L. Rowse, Simon Forman: Sex and Society in Shakespeare’s Age (London: Weidenfeld and Nicholson, 1974); Barbara Traister, The Notorious Astrological Physician of London: Works and Days of Simon Forman (Chicago: University of Chicago Press, 2001); Lauren Kassell, Medicine and Magic in Elizabethan London: Simon Forman, Astrologer, Alchemist, and Physician (Oxford: Oxford University Press, 2005). 78. Ian Mortimer, The Dying and the Doctors: The Medical Revolution in Seventeenth-Century England (Suffolk/Rochester, NY: Boydell, 2009). 79. Pelling, Medical Conflicts in Early Modern London. Published listings or indexes for England used in the same monograph include parish registers and accounts, freemen’s rolls and apprenticeship enrolments, marriage licences, household accounts, denizations, naturalizations, and other records relating to strangers. 80. Adrian Johns, The Nature of the Book: Print and Knowledge in the Making (Chicago: University of Chicago Press, 1998). 81. Vatican City, Biblioteca Apostolica Vaticana, Vat. gr. 278 (= W), which is a transcription of Hippocrates from a Greek manuscript completed by Marco Fabio Calvo (d. c.1527) on 24 July 1512 in preparation of his famous Latin translation of the Hippocratic Corpus printed in 1525. 82. Emidio Campi, Simone de Angelis, Anja-Silvia Goering, and Anthony Grafton (eds), Scholarly Knowledge: Textbooks in Early Modern Europe (Geneva: Droz, 2008). 83. Jole Agrimi and Chiara Crisciani, Les ‘consilia’ médicaux (Turnhout: Brepols, 1994). 84. Gianna Pomata, ‘Sharing Cases: The Observationes in Early Modern Medicine’, Early Science and Medicine 15 (2010), 193–236. 85. William Eamon, Science and the Secrets of Nature: Books of Secrets in Medieval and Early Modern Science (Princeton: Princeton University Press, 1994). 86. Andrea Carlino, Paper Bodies: A Catalogue of Anatomical Fugitive Sheets 1538–1687 (London: Wellcome Institute for the History of Medicine, 1999); Heike Talkenberger, Sintflut: Prophetie und Zeitgeschehen in Texten und Holzschnitten astrologischer Flugschriften 1488–1528 (Tübingen: Niemeyer, 1990). 87. Andreas Speer (ed.), Die Bibliotheca Amploniana: Ihre Bedeutung im Spannungsfeld von Aristotelismus, Nominalismus und Humanismus (Berlin/New York: de Gruyter, 1995); Kathrin Paasch, Die medizinischen Schriften in der Bibliotheca Amploniana (Erfurt: LC Erfurt Amplonius, 2001); Bernd Lorenz, ‘Humanistische Bildung und fachliches Wissen. Privatbibliotheken deutscher Ärzte. I. Teil’, Philobiblon 41 (1997), 128–152; II. Teil, Philobiblon 42 (1998), 253–300; III. Teil, Philobiblon 43 (1999), 294–314; IV. Teil, Philobiblon 44 (2000) 105–51; Anna Manfron (ed.), La biblioteca di un medico del Quattrocento: I codici di Giovanni di Marco da Rimini nella Biblioteca Malatestiana (Torino: Allemandi, 1998); Robert Kolb, Caspar Peucer’s Library: Portrait of a Wittenberg Professor of the Mid-Sixteenth Century (St. Louis: Center for Reformation Research, 1976). 88. Jean A. Givens, Karen M. Reeds, and Alan Touwaide (eds), Visualizing Medieval Medicine and Natural History, 1200–1500 (Aldershot: Ashgate, 2006); Sachiko Kusukawa, Picturing the Book of Nature (Chicago: Chicago University Press, forthcoming). 89. Jonathan Sawday, Engines of the Imagination: Renaissance Culture and the Rise of the Machine (London: Routledge, 2007); Andreas Grote (ed.), Macrocosmos in Microcosmo. Die Welt in der Stube. Zur Geschichte des Sammelns 1450–1800 (Opladen: Leske und Budrich, 1994).

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90. Jane E. Buikstra and Lane E. Beck, Bioarchaeology: The Contextual Analysis of Human Remains (Amsterdam: Elsevier; Boston: Academic Press, 2006); Charlotte A. Roberts and Jane E. Buikstra, The Bioarchaeology of Tuberculosis: A Global View on a Reemerging Disease (Gainesville: University Press of Florida, 2003); Gino Fornaciari et al., ‘The “Medici Project”: First Anthropological and Paleopathological Results of the Exploration of the Medici Tombs in Florence (15th–18th centuries)’, Medicina nei secoli 19 (2007), 521–44; Sachiko Kusukawa and Ian Maclean (eds), Transmitting Knowledge: Words, Images, and Instruments in Early Modern Europe (Oxford: Oxford University Press, 2006); Inge Keil, Augustanus Opticus: Johann Wiesel (1583–1662) und 200 Jahre optisches Handwerk in Augsburg (Berlin: Akademie Verlag, 2000). 91. Anthony Grafton and Nancy Siraisi (eds), Natural Particulars: Nature and the Disciplines in Renaissance Europe (Cambridge, MA: MIT Press, 1999).

Select Bibliography Arrizabalaga, Jon, John Henderson, and Roger K. French, The Great Pox: The French Disease in Renaissance Europe (New Haven, CT/London: Yale University Press, 1997). Brockliss, Laurence, and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997). Cook, Harold J., Matters of Exchange. Commerce, Medicine, and Science in the Dutch Golden Age (New Haven, CT/London: Yale University Press, 2007). Eamon, William, The Professor of Secrets: Mystery, Medicine, and Alchemy in Renaissance Italy (National Geographic, 2010). Findlen, Paula, Possessing Nature: Museums, Collecting, and Scientific Culture in Early Modern Italy (Berkeley, CA: University of California Press, 1994). Green, Monica H., Making Women’s Medicine Masculine: The Rise of Male Authority in Premodern Gynaecology (Oxford: Oxford University Press, 2008). Henderson, John, The Renaissance Hospital: Healing the Body and Healing the Soul (New Haven, CT/London: Yale University Press, 2006). Jacquart, Danielle, Scientia in margine: Études sur les marginalia dans les manuscrits scientifiques du Moyen Âge à la Renaissance (Genève: Librairie Droz, 2005). Park, Katharine, Secrets of Women: Gender, Generation, and the Origins of Human Dissection (New York: Zone Books, 2006). Pelling, Margaret, Medical Conflicts in Early Modern London: Patronage, Physicians, and Irregular Practitioners 1550–1640 (Oxford: Clarendon Press, 2003). Pomata, Gianna, Contracting a Cure: Patients, Healers, and the Law in Early Modern Bologna (Baltimore/London: Johns Hopkins University Press, 1998). Siraisi, Nancy G., The Clock and the Mirror: Girolamo Cardano and Renaissance Medicine (Princeton: Princeton University Press, 1997). Trevor-Roper, Hugh R., Europe’s Physician: The Various Life of Sir Theodore de Mayerne (New Haven, CT: Yale University Press, 2006). Wear, Andrew, Knowledge and Practice in English Medicine, 1550–1680 (Cambridge: Cambridge University Press, 2000).

chapter 5

h e a lt h a n d m edici n e i n the en lightenm en t e. c. s pary

The eighteenth century has particularly attracted medical historians in recent decades. In the 1960s, the field was dominated by studies of hospital medicine and by hagiographic or triumphalist accounts of medical pioneers and cures, mostly written by doctors.1 Then in close succession there appeared a number of key works in the philosophy, sociology, and social and cultural history of medicine. Publications by the French philosopher Michel Foucault (1926–84), the British social historian Roy Porter (1946–2002), the German historian Barbara Duden (1946–), and others ensured that the principal foundations of the social and cultural history of eighteenth-century medicine were laid within little over a decade.2 These new historiographical developments typically adopted a revisionist stance. Social historians offered medical ‘history from below’ as a counter to top-down, profession-centred approaches, while cultural historians insisted upon the contingency of medical language and meaning. For Foucault, medicine became implicated in the exercise of government towards the end of the eighteenth century, extending disciplinary control and surveillance into the fabric of the body itself. His expositions of the links between medical knowledge and politics, like those of his scholarly contemporaries Ivan Illich (1926–2002) and Thomas Szasz (1920–), were taken by some to undermine the ethical justification for medical intervention and hence as a threat to the Western medical enterprise. For this reason, Foucault’s work remains controversial and has never been fully integrated into the history of medicine. Certainly it broke radically with the naïve accounts of language, power, and the body upon which medical history had previously rested. Medicine would never again be viewed as an epistemologically innocent transaction between altruistic medical practitioners and the passively grateful beneficiaries of their skills, a model that had been invented during the later eighteenth century as the balance of medical power passed, with government sanction, from elite clients to licensed medical practitioners.3 That transformation was by no means inevitable, for, as cultural historians have observed, a flourishing medical marketplace characterized eighteenth-

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century medical practice. Commodification and print gave sick people increased autonomy, transforming their experience of disease, cure, and health. The implications of eighteenth-century medicine’s status as a form of consumption catering to Enlightened preoccupations with self-knowledge, autonomy, and commerce are still being explored by historians.4 Large-scale studies of communities of medical practitioners in different parts of Europe, meticulously crafted by social historians, are also providing a much richer and more complete picture of the nature and profitability of medical services, and the social origin, training, and daily activities of those who qualified to practise medicine.5 The eighteenth century continues to be viewed as a critical period in the history of medicine, as the century when bodies became the subject of large-scale political intervention, from centralized responses to plague epidemics or mass inoculation programmes early in the century to the growing use of mortality tables at its end. The body, indeed, is central to the transformations of eighteenth-century medical historiography. Once the unproblematic subject of medical interventions, it has become the site of lived experience, a palimpsest on which medical, political, and personal authority are inscribed, and a key locus for the fashioning of identity, subjectivity, and selfhood. Anthropologists, philosophers, and sociologists have constituted the toolkit of a new history of medicine that no longer takes the claims of medical practitioners about the nature of disease, health, and cure at face value.6

Medical practice: orthodoxy, reform, and challenges Only some medical practitioners had access to learned and print culture throughout the eighteenth century: the physicians, surgeons, and apothecaries. Their training and roles were socially, legally, and historically distinct. Physicians had a university training based on the classics—Hippocrates, Galen, and others. Unlike surgeons, they eschewed physical contact with the sick, reasoning instead about the cause and progress of disease from symptoms described by their clients. Qualifying to practise required years of training and medical degrees and faculty membership were usually expensive. A degree generally only conferred a formal right to practise within a particular territory, but rewards were potentially large, for physicians catered to the social elite. Surgeons conducted operations on a range of conditions demanding manual intervention, such as bladder stone or fistula, as well as letting blood. Apothecaries prepared prescriptions on behalf of physicians and also made and sold many other medical and semi-medical goods. In practice, although diagnosis and prescription were often legally apportioned to doctors, particularly in towns, other medical practitioners, licensed or unlicensed, routinely engaged in both activities. The policing of the boundaries between different forms

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of medical and commercial practice by municipal and governmental administrators was erratic, ineffective, and venal, something that medical practitioners of all stripes exploited to considerable profit. Licensed practitioners invoked their legal privileges to call for the suppression and regulation of unlicensed, privileged, or even other licensed practitioners. From the start of the eighteenth century, however, individual celebrity practitioners and medical entrepreneurs, licensed or not, attracted powerful support in noble and courtly circles with spectacular public cures or new remedies. So the supply of medical services was uneven, reflecting local quirks of the medical market or medical patronage as well as centralized legislation.7 Physicians were usually the wealthiest of the licensed medical practitioners, commanding a large fee for their consultations and prescriptions, and moving in the upper echelons of middling society. Many individual surgeons and apothecaries also became exceptionally wealthy from the end of the seventeenth century onwards, ranking among the most successful and prominent of urban merchants. However, physicians consorted with their gentlemanly clients on nearly equal terms, because their university training was deemed to raise them above the status of merchants. This medical pecking order had prevailed in European societies since the Middle Ages. What changed during the eighteenth century, with significant effects upon medical practice, was that other sorts of medical practitioners began to lay claim to higher status, appealing to forms of knowledge and skill outside the traditional purview of doctors. Apothecaries reinvented themselves as pharmacists on the basis of their chemical and botanical knowledge, while surgeons presented themselves as anatomical and physiological experts. The command of a specialist skill and the formation of ties to metropolitan scientific societies allowed these subordinate medical groups to distance themselves from claims that they were nothing more than mindless mechanics, and to charge physicians, in their turn, with lacking essential knowledge about the body and remedies. The eighteenth century was thus a period of consolidation and institutionalization of surgical and pharmaceutical authority, admittedly in a rather piecemeal way. New and well-funded institutions appeared towards the end of the century, such as the Collège de Pharmacie in Paris, founded in 1777, or the Royal College of Surgeons in 1800. The training these offered to pharmacists and surgeons allied the specialist knowledge acquired from a university medical education, such as Latin or philosophy, with new scientific domains. Surgeons’ and apothecaries’ bids for gentlemanly status thus rested on appropriating both old and new forms of learning.8 These three licensed groupings of medical practitioners probably represented a numerical minority of healers in Europe as a whole, however. Alongside them, in cities, courts, towns, and villages, there flourished a host of unincorporated healers: toothpullers, wise women, patent remedy vendors, herbalists, pedlars, diviners, astrologers, and faith healers. Sick people had access to a broad range of treatments founded on sometimes incommensurable therapeutic claims, from balneology and panaceas to astrology and spells. From a client’s point of view, the medical encounter was a process of auto-experimentation, with fidelity to one particular practitioner or therapy often challenged by rumours, recommendations, and news about other, more efficacious

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treatments, more knowledgeable practitioners, or more reliable accounts of the nature and likely progress of a disease. New treatments constantly came into or fell from favour, and there was no centralized framework for generating faith in one set of remedies and doctrines over another. Individual experience, personal endorsements, and published case histories, as well as advertising (an innovation of this period) and news, were the dominant forms of proof. Medicine was closely connected to the public sphere, and the circulation of print brought news of novel medical treatments and traditional medical advice even to the poor and those most distant from metropolitan areas.9 Access was also a matter to reckon with: rural areas possessed few licensed practitioners and much medical treatment, particularly for the poor, was carried out by local healers with an established reputation or a particular sovereign cure, or relied upon the domestic preparation of remedies recorded in receipt books kept over generations, alongside recipes for home-made pies and paint. Urban medical clients had access to a far larger range of different kinds and styles of medical practice, including the latest in medical innovations, be it a new hernia truss, diet, or elixir.10 Women were formally excluded from most medical training and medical practice throughout the eighteenth century. However, they retained responsibility for medical care within the home and over certain circumscribed areas, such as women’s diseases and childbirth. Their long monopoly over these aspects of healing and health would be broken during the later part of the century, as licensed male practitioners endeavoured to assert a more comprehensive authority over medical practice in general. Recourse to ‘man-midwives’, the abandonment of swaddling, and the replacement of wet-nursing by maternal breastfeeding first became fashionable in the higher social echelons and were heavily promoted by elite physicians. As in their dealings with subordinate groups of licensed medical practitioners, organized associations of physicians courted certain legal and social rights over midwives and hospital nurses (in some places predominantly drawn from religious orders), such as the right to limit their powers, reform their organization and training, or inspect their work. They also sought to eradicate female healers or wise women from medical practice in many areas, though with limited success.11 In such cases, licensed medical practitioners tended to pursue a common strategy: they appropriated certain useful skills or treatments controlled by other practitioners, while diminishing their claim to expertise and medical knowledge, thus depriving their rivals of both public authority and epistemological and social credibility. Licensed practitioners possessed an institutional sanction and social authority to which rival groups of healers could rarely aspire unless they, too, formed an organized body. The most effective challenges to the authority of physicians, accordingly, came from organized groups such as nursing sisters, midwives, barber-surgeons, or apothecaries. The diversity of medical practice and the power of choice possessed by medical clients tended, however, to outweigh attempts by both licensed practitioners and rulers to exert a centralized medical hegemony. In fact, rulers themselves tolerated or actively fostered challenges to the authority of established medical guilds and faculties, favouring individual medical entrepreneurship or new medical administrative bodies more directly under their control. This was the case both in the Hapsburg Empire, where in 1784 the Emperor Joseph

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founded the Josephinum, a medical and surgical academy, as a rival to the medical faculty in Vienna, and in France, where King Louis XVI chartered the Société Royale de Médécine in 1778, charging it with vetting medical inventions and administering nationwide public health programmes.12

Medicalization: imposition or appropriation? The eighteenth century has been described as a time of increasing medicalization of Western societies. Though this is usually portrayed as a growth in the power of medical practitioners over ordinary life, in practice it may also be understood as an increasing embrace of the medical by lay people. The expression ‘medical marketplace’ aptly captures the relationship between medical clients and even the best qualified of medical practitioners in this period.13 Particularly in urban settings, ordinary people had ample opportunity to acquaint themselves with recent developments in both medicine and the sciences, and exercised choice among a wide range of medical practitioners. The onus was on sick people themselves to take responsibility for health management by becoming knowledgeable about physiology and medicine, and to implement such knowledge within their own lifestyle. Over the course of the century, the market for medical care and especially for health products and advice grew substantially. Devices and remedies for treating or preventing practically every known ailment proliferated, from ‘Liquid Snuff ’ and Dover’s Powders to baths and eyeglasses. By mid-century, domestic health manuals were a highly successful literary genre, with books like William Buchan’s Domestic Medicine (1769), John Wesley’s Primitive Physick (1747), and Samuel-André Tissot’s Avis au peuple (1763)—not all of them written by physicians—among the bestknown publications.14 Such works generally used a standard model of pathology, therapy, and above all hygiene or preventative medicine, drawn from customary university fare: humoral medicine, based on Hippocratic and Galenic principles. Regimen, or the management of the six non-naturals—sleeping and waking, eating and drinking, motion and rest, evacuation and retention, airs, and passions—was central to the cure and prevention of disease, as to everyday life. Knowledge of one’s own constitution, which reflected the proportion of the four classical humours (melancholic, bilious, sanguine, or phlegmatic) in the body, still shaped many features of daily life, social relations, and household management. Self-knowledge was central to the corporeal self-construction of most people with at least some access to print culture and took priority over the authority of medical practitioners. In regimen medicine, the emphasis was very much upon the epistemological autonomy, individuality, and accountability of the sick person, rather than the universal interchangeability of all bodies. Disease was often portrayed as a consequence of personal errors of regimen, commonly resulting from a failure to exercise proper rational

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self-control and the development of long-term bad habits. Descriptions of disease in case histories accordingly became extended narratives of lifestyle. At the same time, diseases were naturalized: no longer regarded as special providential interventions or punishments for religious transgressions, they were more usually explained as natural phenomena requiring natural explanations. This process of secularization meant that disease mutated into a mark of the state of rationality of individuals and their degree of control over their bodies. The exercise of hygiene or expectant medicine now became the hallmark of rational secular virtue.15 The onus on individuals to embrace responsibility for their own health through the acquisition of reason and scientific knowledge engendered new definitions of irrationality as pathology.16 The reinvention of hygiene provided a platform for calls not only for individual, but also for social, reform. The political implications of health programmes, in which the reform of the self benefited the condition of the nation as a whole, are clearly evident in radical proposals for the reform of daily life, such as low regimen or vegetarianism. Where disease was a matter of lifestyle, it could be closely linked to socially differentiated practices, such as the consumption of exotic or luxury foods. Males who lived luxuriously were more likely to suffer from gout or nocturnal pollutions, while peasants were deemed to have coarser, more robust bodies. By penning descriptions of diseases and their causation and cure, physicians could thus make moral pronouncements on the conduct prevailing in different walks of life. Medical critiques of luxury and intemperance, or of bad habits, rested on the claim that these left indelible physiological traces that might only manifest themselves in later life. This medical politics of consumption allowed great scope for individual self-fashioning.17 The variability of constitutions, coupled with growing faith among educated elites in the power of the individual to accomplish health as aesthetic and moral performance, may be contrasted with other contemporary claims: that there were innate and fixed differences between persons of different sexes or cultures, reflected in physiology and anatomy. For practical therapeutic purposes, constitution outweighed anatomy; women were widely considered to possess softer and more humid bodies than men. From around the 1770s, the ‘masculine’ body, characterized by robustness and physical strength, became a qualification for political participation in many places—as well as fuelling an extensive market in exercise products. The presentation of certain corporeal characteristics as a condition of civic enfranchisement meant that women and others who departed from such standards could increasingly be excluded from full civic status, resulting in a polar opposition between masculinity and femininity or effeminacy that appeared to be legitimated by anatomy, humoral theory, and moral medicine. The humoral body and gender-specific legislation were nothing new; what changed was the reinvention of masculinity as tied to a particular bodily condition, to natural laws superseding the diversity of rank and birth. This appeal to embodiment helped to overturn certain features of the early modern social order in many Western cultures between 1700 and 1800.18 Such concerns are evident in the upsurge of interest in conditions such as onanism or gout as the consequences of lifestyle. Onanism was said to be encouraged by the

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accumulation of excessive nutritive juices within the body, and deprived the body of the subtle vital principles that ensured masculine health and vigour. Urban life fostered the emergence of hitherto unknown diseases, such as vapours, hysteria, and hypochondria, deemed to affect women and luxurious or sedentary males in particular. Sensibility, regarded as a generic and desirable characteristic of polite minds and bodies during the earlier part of the century, became increasingly gendered and pathologized and finally dwindled into sentimentality, a facile emotional state best suited to women and the old. The political implications of gender were thus increasingly naturalized during this period. The creation of a ‘feminine’ body was, to some extent, a by-product of the reinvention of masculinity as an ideal political and corporeal state in this period. It would be taken up in contemporary calls for women to limit themselves to child-bearing and household management.19 Medical constructions of race served similar purposes, creating corporeal and mental models appropriate to the politically enfranchised and legitimating the exclusion of those who did not fit such ideals from the polity. By the same token, however, critics of such exclusionist views often appealed to the plasticity of the humoral body and mind to undermine claims that particular groups should desist from political commentary and practice. Again, as secular naturalistic explanations replaced religious ones, the state of the body could be closely tied to the proper functioning and future of society.

Colonial medicine A climatic or atmospheric model of disease was espoused by virtually all physicians during the latter part of the eighteenth century. The body was widely understood as a permeable system of humours or fluids, flowing in channels and interchanging materials with the atmosphere through pores. Diseases might arise from blockages to flow, or else from atmospheres poisoned or imbalanced in terms of humidity or temperature. Disease symptoms such as pus or diarrhoea were a beneficial sign, attesting to nature’s efforts to purge the body of harmful and corrupted humours. The skin formed a major excretory site; throughout the century, experimenters reaffirmed the significance of insensible (or imperceptible) cutaneous transpiration as a route for daily losses of food and drink. The presence of nutritive as well as harmful particles in the air was supported by the chemical experimentation of natural philosophers such as Stephen Hales (1677–1761) in the 1730s, but an even more intense interest in the purity and composition of the air emerged from the 1770s onwards, following the claim by the English dissenting chemist Joseph Priestley (1733–1804) that atmospheric air was not an element, but a mixture of several different species of airs, later termed ‘gases’. This new pneumatic medicine gave rise to commercial ramifications such as the production of artificial mineral waters, aerial therapy establishments and baths, while physicians addressed the problems of miasmata created by sites of putrefaction such as slaughterhouses, cemeteries, sewers, ships’

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bilges, and mines, incorporating ventilation systems into new hospitals. Early disinfectants served aerial purification, not the eradication of germs.20 Similar concerns with atmospheric effects upon the body underlay much of colonial medicine in the second half of the eighteenth century. In colonies, medical practitioners, colonists, slaves, and indigenous inhabitants grappled with unfamiliar diseases and alien healing practices; much medical treatment was undertaken by slaves. Colonial societies, dominated by immigrants from several different parts of the world, were fragile and transient populations fraught with tensions, not least of which was the high mortality rate affecting both whites and blacks newly arrived in the colonies. Contemporary medical practitioners explained these deaths as the result of exposure to a climate other than the victim’s native one; a process of physiological readjustment, often accompanied by fever, was required for all immigrants to acclimatize to the new conditions. As James Lind (1716–94), the British physician best known for curing the climatogenic disease of scurvy with lime juice, put it in 1768: ‘By length of time, the constitution of Europeans becomes seasoned to the East and West Indian climates, if it is not injured by repeated attacks of sickness, upon their first arrival. Europeans, when thus habituated, are generally subject to as few diseases abroad, as those who reside at home.’21 The importation of African slaves was justified by claiming that their origin in the torrid zone would make the shock of transplantation less severe; people born in the colonies were also deemed less at risk from the effects of a hot climate. Colonies therefore became experimental sites at which the predictions of medical topography could be assessed. However, they were merely one node of the extensive networks of enquiry into medical topography that preoccupied medical societies and rulers around Europe. The correlation of climatic and topographical observations with the local incidence of particular diseases, especially epidemics, would, it was argued, yield a complete picture of the connections between climate, government, and illness.22 This was especially important in light of concerns about the growing consumption of exotic remedies and foodstuffs such as ipecacuanha, quinquina, coffee, and tea. Early modern missionary naturalists and colonial surgeons actively promoted European therapies abroad, and sought out new exotic remedies. The Jesuits’ long-standing monopoly over the trade in cinchona bark was followed, in the eighteenth century, by large-scale attempts to collate descriptions and specimens of natural productions world-wide, aimed at disclosing their medicinal virtues. Exotic resources and colonial plantations became increasingly important sources of revenue for trading companies or rulers, as European consumption of exotic materia medica and foods took off exponentially. Because the long-distance food and drugs trade was usually monopolized by foreigners, druggists, apothecaries, or wholesalers, critiques of globalization and of exotic consumption after 1650 were often articulated by physicians threatened by these medical rivals. The notion of health as a virtuous condition to be accomplished by prevention, not cure, was tied to charges that pharmacy, with its emphasis on chemistry and the exotic, supplied an illusion of treatment, closer to poison than cure. It was among physicians that the call to conduct research into import substitutes found its strongest voice.23

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Experimental therapies Pneumatics and hydrostatics were just two of the numerous areas in which mathematical and experimental natural philosophy shaped medicine. The rise of iatromechanism in the early decades of the century as the main challenger to seventeenth-century iatrochemical programmes was exemplified in the appearance of mechanistic accounts of the animal economy. Physicians like the Scottish medical professor Archibald Pitcairne (1652–1713), or the Armenian Gjuro (Giorgio) Baglivi (1668–1707), reinvented the body as a mechanical system of interacting parts. The subtle fluids and active principles investigated by natural philosophers over the next decades were also quickly imported into medical practice and commerce. Electricity, experimentally demonstrated from the 1740s onwards, rapidly yielded new medical therapies for conditions such as toothache and paralysis, which were trialled in private salons, academic laboratories, and even new public institutions. The founder of Methodism, John Wesley (1703–91), strongly advocated electrical therapies, speculating that ‘the one and only Elementary or pure Fire’ might be the cause of ‘the vulgar Culinary fire’ as well as ‘the vital Flame supposed to be the Cause of all the Motions in the Body of Man . . . and what if the Nervous Juice itself be a Fluid of this kind?’, a prediction given strong support by the experiments of the Bolognese physician Luigi Galvani (1737–98) at the century’s end. At the ‘Temple of Health and Hymen’ run by James Graham on Pall Mall, London, clients were treated to an electrified ‘Celestial Bed’ that guaranteed the production of perfect offspring for one crown.24 Similar commodification occurred in the case of magnetism. In 1781, a Viennese physician, Dr. Franz Anton Mesmer (1734–1815), settled in Paris, offering specialized therapy to redirect the flow of animal magnetism (the vital form of the magnetic fluid) through the body so as to remove blockages and restore health. The treatment rapidly became fashionable, recruiting new clients and practitioners inside and outside France. However, unlike medical electricity, animal magnetism did not command widespread institutional support; the privileging of the practitioner’s body and the altered moral and physical state of the (often female) client nudged the boundaries of sexual propriety and political order.25 The pursuit of medical electricity and animal magnetism demonstrates the extent of contemporary interest in the special nature of the powers governing the animal body. Around 1710, physiological phenomena were being explained in terms of chemical ferments or mechanical movements. By the 1730s, claims by the German physician Georg Ernst Stahl (1659–1734) that animal movements were governed by a soul were being appropriated for new accounts in which bodily phenomena were chemically and physiologically distinct from the phenomena to which brute matter was subject. A vital principle governed living bodies, rendering them fundamentally distinct from non-living nature. These explanatory models are often collectively termed ‘vitalism’, though they varied considerably across time and space.26

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Medical centralization and local diversity Over the course of the eighteenth century, the centralized management of disease became a key concern of administrations around Europe. This medical bureaucracy rested upon new techniques for making medical facts, such as the collation of disease observations and their reduction to quantitative and tabular form, often by medical and scientific societies and institutions. Mortality tables, invented in the second half of the seventeenth century, now became a key instrument in the construction and surveillance of populations as new medical entities. In some countries, such as the Hapsburg Empire, national networks of medical officials were created to coordinate the management of epidemics and health scares, such as outbreaks of plague and vampirism in the early eighteenth century. This use of government bureaucracy, authority, and ultimately force to manage the health of populations fell under the general rubric of medical police, a programme explicitly articulated in continental Europe, though less so in Britain. The leading publications on the subject were written by German authors such as Johann Heinrich Gottlob von Justi (1717–71) and Johann Peter Frank (1745–1821), who treated health as part of cameralism, the science of resource management on behalf of the state. Medical police embraced all those aspects of medicine concerning the population as a national resource. In general, prior to the appearance of Thomas Malthus’s An Essay on the Principle of Population in 1798, most physicians held that the European population was in decline, and extensive state resources were devoted to redressing the situation. Several of the priorities of medical police were thus diametrically opposed to those of nineteenth-century public health programmes. It has been suggested that medical police was synonymous with public health and hygiene; in fact its agenda was far broader, concerned with the maintenance of moral order and social hierarchy, the administration of charity, and the regulation of commerce. It covered everything from occupational disease, prostitution, and abandoned children, to issues of public safety such as the adulteration of food and drink, dangerous materials, and miasmata.27 Quantification and surveillance were characteristic of several large-scale programmes for the management of health. The best studied of these, inoculation, derived from nonEuropean practices in West Africa and the Ottoman Empire. This unfamiliarity and the difficulty of reconciling the practice of smallpox inoculation with European models of the humoral body were major reasons why, despite government support for inoculation programmes around the Western world from the 1720s onwards, the execution of this prophylactic measure was resisted in many areas, so that inoculation sometimes had to be forcibly imposed. If controversial, inoculation nonetheless illustrates the changing relationship between medical clients and medical authority. Inoculation programmes did away with the variability of individual constitutions in favour of extensive, population-oriented, disciplinary medical interventions. The public debate that accompanied most successful new therapies raged especially fiercely in the light of the powerful

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government support commanded by inoculation campaigns in many areas, and the impressive scale on which they were implemented.28 The fate of inoculation programmes indicates the extent to which centralization and medicalization conflicted or were accommodated with local knowledge and practices.29 Inoculation and other mass medical practices succeeded best where medical subjects were comparatively powerless or confined within disciplinary spaces (hospitals, prisons, workhouses, and ships). In such circumstances, hygiene could more readily be translated from individual selfgovernance to the large-scale management of interchangeable bodies.30

The reinvention of the clinic For much of the eighteenth century, hospital care in Europe was managed by members of religious orders, as in previous centuries. At Leiden, the polymathic physician Herman Boerhaave (1668–1738) introduced regular bedside visiting and diagnosis. These practices were taken up in Edinburgh, Vienna, and Pavia. Over the course of the century, hospital care became increasingly secularized and differentiated from general charitable relief. The widespread introduction of triage allowed the indigent, elderly, and foundlings to be separated from the sick and insane. Hospitals were reformed and sometimes redesigned to incorporate the latest scientific claims about disease transmission, nourishment, and ventilation. Extensive publicity campaigns presented old-style hospitals as unhygienic deathtraps, preserves of unreason and inhumanity.31 A new public representation of the modern hospital as a centre of secular, enlightened, hygienic medical care emerged, and at its heart was the clinic. In the closing years of the century, clinical medicine changed in approach: formerly based upon patient narratives, the new clinical medicine increasingly relied on an external diagnosis of internal conditions, in which the sick person’s self-narration played no role. A practice formerly reserved to surgeons, that of conducting autopsies on the deceased, was appropriated to serve clinical medicine more generally, especially with the rise of a new pathology of lesions—damage to the internal organs whose presence could be deduced from a variety of signs elicited by new medical practices such as auscultation and confirmed by observation at autopsy. In such circumstances, case histories assumed a secondary importance, as physical examination dominated the medical encounter. This shift was made possible by the erosion of old boundaries between physicians, surgeons, and pharmacists during sweeping reforms of the medical profession and hospital organization between 1770 and 1830. A doctor’s training now routinely included surgical and chemical knowledge.32 The conversion of hospitals into disciplinary spaces denoted a new set of power relations between the body and knowledge: the autonomy and constitutional uniqueness of the medical client outside the hospital had to cede to the interchangeable, quantifiable body surveyed by medical practitioners. In Paris, where the new clinical model dominated, hospitals became sites for teaching, research, and medical treatment, rather than places of charitable care. For many decades, fluctuations in

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funding and administrative disarray caused by the French Revolution meant that hospital care was, if anything, inferior to what it had been under the old system. However, the principles of evaluating hospitals as places of medical care by measuring mortality rates, of utilizing them as experimental and disciplinary sites for advancing new programmes of bodily knowledge and medical therapy, and of actively involving medical practitioners in the daily care of the sick became firmly established in the closing years of the century. Parisian clinical medicine would become a model for nineteenth-century medical practice in other parts of the world; many doctors trained in Paris before returning home to practise. The transformation of medicine at the very end of the century thus represented a shift both in the training of medical practitioners and in accounts of the body.33

Conclusion Was there an ‘Enlightened medicine’? Most eighteenth-century medical practitioners, like their elite clients, laid claim to being enlightened in the continental sense of cultivating reason. The peculiarly Anglophone hunt for a singular Enlightenment, characterized by religious heterodoxy and political reform and tolerance, causes problems when extended to medicine. Although many physicians figure in the Enlightenment canon, such as John Locke (1632–1704), Julien Offray de La Mettrie (1709–51), and Bernard Mandeville (1670–1733), many others, surely the bulk of medical practitioners, were orthodox in their religious and political views.34 The search for a specifically medical Enlightenment may be something of a red herring, yet the body, as a material and natural object, did become more central to knowledge projects during the eighteenth century, as demonstrated by the increased interest in mortalism, the view that the physical body would participate in the Resurrection, or in the non-naturals and the passions.35 From around 1650 or so, there was much debate over the relationship between the body and reason, and over the extent to which physiology should underpin politics. The Declaration of the Rights of Man, which formed the foundational document of the moderate French Revolution, had as its first article the assertion that men were naturally free and equal. However, that such claims about the relationship between reason, embodiment, and nature did not translate in a straightforward manner to medicine is evident from the fact that the same Revolution also abolished formal medical qualifications and education.36 In other words, medical practitioners had no monopoly over the natural laws of the body, and programmes for a medical Enlightenment were as diverse and contradictory as in other attempts to reform knowledge. To portray these knowledge projects in all their complexity, historians still need to embrace the full implications of treating eighteenth-century medical knowledge as a political enterprise. It is here, in the mapping of the ‘moral geography’ of eighteenth-century medicine, that the most interesting avenues of historical enquiry await further investigation.37

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Notes 1. George Rosen, A History of Public Health (New York: M.D. Publications, 1958); Leslie T. Morton and Robert J. Moore, A Bibliography of Medical and Biomedical Biography (Aldershot: Scolar, 1989). 2. Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (London: Tavistock, 1973); Roy Porter, A Social History of Madness: Stories of the Insane (London: Weidenfeld and Nicolson, 1987); Barbara Duden, Geschichte unter der Haut: ein Eisenacher Arzt und seine Patientinnen um 1730 (Stuttgart: Klett-Cotta, 1987). 3. Nicholas Jewson, ‘The Disappearance of the Sick-Man from Medical Cosmology, 1770– 1870’, Sociology 10 (1976), 225–44. 4. Colin Jones, ‘The Great Chain of Buying: Medical Advertisement, the Bourgeois Public Sphere, and the Origins of the French Revolution’, American Historical Review 101 (1997), 13–40. 5. Ole Peter Grell, Andrew Cunningham, and Robert Jütte (eds), Health Care and Poor Relief in 18th and 19th Century Northern Europe (Aldershot: Ashgate, 2001); David Gentilcore, Healers and Healing in Early Modern Italy (Manchester: Manchester University Press, 1998). 6. Bryan S. Turner, The Body and Society: Explorations in Social Theory (Oxford: Blackwell, 1984); Nikolas Rose, Governing the Soul: The Shaping of the Private Self (London: Routledge, 1989). 7. Laurence Brockliss and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997); Margaret Pelling, ‘Medical Practice in Early Modern England: Trade or Profession?’, in Wilfrid Prest (ed.), The Professions in Early Modern England (London: Croom Helm, 1987), 90–128; Teresa Ortiz Gómez, Carmen Quesada Ochoa, José Valenzuela Candelario, and Mikel Astrain Gallart, ‘Health Professionals in Mid-Eighteenth Century Andalusia: Socio-Economic Profiles and Distribution in the Kingdom of Granada’, in John Woodward and Robert Jütte (eds), Coping with Sickness: Historical Aspects of Health Care in a European Perspective (Sheffield: European Association for the History of Medicine and Health Publications, 1995), 19–44. On privileged physicians, see Vivian Nutton (ed.), Medicine at the Courts of Europe, 1500–1837 (London: Routledge, 1990). 8. Toby Gelfand, Professionalizing Modern Medicine: Paris Surgeons and Medical Science and Institutions in the 18th Century (Westport, CT: Greenwood Press, 1980); Susan C. Lawrence, ‘Private Enterprise and Public Interests: Medical Education and the Apothecaries’ Act, 1780–1825’, in Roger French and Andrew Wear (eds), British Medicine in an Age of Reform (London/New York: Routledge, 1991), 45–73. 9. William Coleman, ‘The People’s Health: Medical Themes in Eighteenth-Century French Popular Literature’, Bulletin of the History of Medicine 51 (1) (1977), 55–74; Roy Porter ‘The People’s Health in Georgian England’, in Tim Harris (ed.), Popular Culture in England, c. 1500–1850 (London: Macmillan, 1995), 124–42; Jones, ‘Great Chain of Buying’; Louise Hill Curth (ed.), From Physick to Pharmacology: Five Hundred Years of British Drug Retailing (Aldershot: Ashgate, 2006). 10. Sara Pennell and Elaine Leong, ‘Recipe Collections and the Currency of Medical Knowledge in the Early Modern “Medical Marketplace” ’, in Mark S. R. Jenner and Patrick Wallis (eds), Medicine and the Market in England and Its Colonies, c. 1450–c. 1850 (London: Palgrave Macmillan, 2007), 133–52; Thomas A. Horrocks, Popular Print and Popular

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11.

12.

13.

14.

15.

16.

17.

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Medicine: Almanacs and Health Advice in Early America (Amherst: University of Massachusetts Press, 2008). Brockliss and Jones, Medical World, 610–17; Adrian Wilson, The Making of Man-Midwifery: Childbirth in England, 1660–1770 (Cambridge, MA: Harvard University Press, 1995); Nina Rattner Gelbart, The King’s Midwife: A History and Mystery of Madame du Coudray (Berkeley/London: University of California Press, 1998). Manfred Skopec, ‘Development of Hygiene in Austria’, in Teizo Ogawa (ed.), Public Health: Proceedings of the 5th International Symposium on the Comparative History of Medicine: East and West (Tokyo, Saikon, 1981), 128–44; Johannes Winmer, Gesundheit, Krankheit und Tod im Zeitalter der Aufklärung: Fallstudien aus den habsburgischen Erbländern (Wien: Böhlau, 1991); Matthew Ramsey, Professional and Popular Medicine in France, 1770–1830: The Social World of Medical Practice (Cambridge: Cambridge University Press, 1988). Roy Porter, Health for Sale: Quackery in England 1660–1850 (Manchester/New York: Manchester University Press, 1989); Mark S. R. Jenner and Patrick Wallis (eds), Medicine and the Market in England and Its Colonies, c. 1450–c. 1850 (Basingstoke: Palgrave Macmillan, 2007); Jean-Pierre-Goubert (ed.), La médicalisation de la société française, 1770–1830 (Waterloo, Ontario: Historical Reflections Press, 1982). William Coleman, ‘Health and Hygiene in the Encyclopédie: A Medical Doctrine for the Bourgeoisie’, Journal of the History of Medicine 29 (1974), 399–421; Roy Porter (ed.), The Popularization of Medicine, 1650–1850 (London/New York: Routledge, 1992); Dorothy Porter and Roy Porter, Patient’s Progress: Doctors and Doctoring in Eighteenth-Century England (Cambridge: Polity Press, 1989), 97, 150; Georges Vigarello, Histoire des pratiques de santé: Le sain et le malsain depuis le Moyen Age (Paris: Editions du Seuil, 1999); Michael Stolberg, Homo patiens: Krankheits- und Körpererfahrung in der frühen Neuzeit (Köln: Böhlau, 2003); Deborah Madden, ‘A Cheap, Safe and Natural Medicine’: Religion, Medicine and Culture in John Wesley’s Primitive Physic (Amsterdam: Rodopi, 2007). Sean M. Quinlan, The Great Nation in Decline: Sex, Modernity and Health Crises in Revolutionary France, c. 1750–1850 (Aldershot: Ashgate, 2007); Porter and Porter, Patient’s Progress, Chapter 3. On religion and medicine, see the essays in Ole Peter Grell and Andrew Cunningham (eds), Medicine and Religion in Enlightenment Europe (Aldershot: Ashgate, 2007). On the non-naturals, see Antoinette Emch-Dériaz, ‘The Non-Naturals Made Easy’, in Porter (ed.), The Popularization of Medicine, 134–59. There are conflicting interpretations of the extent of what Michel Foucault termed the ‘great confinement’ of the mad that began in the 1660s: Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Pantheon, 1965); Roy Porter, Mind-Forg’d Manacles: A History of Madness in England from the Restoration to the Regency (London: Athlone Press, 1987); Andrew Scull, Charlotte MacKenzie, and Nicholas Hervey, Masters of Bedlam: The Transformation of the Mad-Doctoring Trade (Princeton: Princeton University Press, 1996). Anita Guerrini, Obesity and Depression in the Enlightenment: The Life and Times of George Cheyne (Norman: University of Oklahoma Press, 2000); Lucia Dacome, ‘Living with the Chair: Private Excreta, Collective Health and Medical Authority in the Eighteenth Century’, History of Science 39 (2001), 467–500; Colin Spencer, The Heretic’s Feast: A History of Vegetarianism (London: Fourth Estate, 1993); Timothy Morton, Shelley and the Revolution in Taste: The Body and the Natural World (Cambridge: Cambridge University Press, 1994); Roy Porter and George S. Rousseau, Gout: The Patrician Malady (New Haven,



18.

19.

20.

21.

e. c. spary CT: Yale University Press, 1998); Roy Porter, ‘Gout: Framing and Fantasizing Disease’, Bulletin of the History of Medicine 68(1) (1994), 1–28. On the debate over whether male and female bodies were anatomically and physiologically distinct, see: Londa Schiebinger, ‘Skeletons in the Closet: The First Illustrations of the Female Skeleton in Eighteenth-Century Anatomy’, Representations 14 (1986), 42–82; Wendy Churchill, ‘The Medical Practice of the Sexed Body: Women, Men, and Disease in Britain, circa 1600–1740’, Social History of Medicine 18(1) (2005), 3–22; Karen Harvey, Reading Sex in the Eighteenth Century: Bodies and Gender in English Erotic Culture (Cambridge: Cambridge University Press, 2004); section ‘Critiques and Contentions’, Isis 94(2) (2003), 274–313. On political legitimacy and corporeal condition, see Patricia Vertinsky, ‘The Social Construction of the Gendered Body: Exercise and the Exercise of Power’, International Journal of the History of Sport 11(2) (1994), 147–71; Georges Vigarello (ed.), Le gouvernement du corps (Paris: Seuil, 1993). Thomas Laqueur, Solitary Sex: A Cultural History of Masturbation (New York: Zone, 2003); Michael Stolberg, ‘An Unmanly Vice: Self-Pollution, Anxiety, and the Body in the Eighteenth Century’, Social History of Medicine 13(1) (2000), 1–21; Anne C. Vila, Enlightenment and Pathology: Sensibility in the Literature and Medicine of EighteenthCentury France (Baltimore/London: Johns Hopkins University Press, 1998), Ch. 7; Anne Vincent-Buffault, The History of Tears: Sensibility and Sentimentality in France (Basingstoke: Macmillan, 1997); Fernando Vidal, ‘Onanism, Enlightenment Medicine, and the Immanent Justice of Nature’, in Lorraine Daston and Fernando Vidal (eds), The Moral Authority of Nature (Chicago/London: University of Chicago Press, 2004), 254–81; Lindsay Wilson, Women and Medicine in the French Enlightenment: The Debate over Maladies des Femmes (Baltimore: Johns Hopkins University Press, 1993), Ch. 6; Günter B. Risse, ‘Hysteria at the Edinburgh Infirmary: The Construction and Treatment of a Disease, 1770–1800’, Medical History 32 (1988), 1–22; Roy Porter and Dorothy Porter, In Sickness and In Health: The British Experience 1650–1850 (London: Fourth Estate, 1988), Ch. 12; John Mullan, ‘Hypochondria and Hysteria: Sensibility and the Physicians’, Eighteenth Century: Theory and Interpretation 25(2) (1983), 141–74; Roy Porter, ‘Civilisation and Disease: Medical Ideology in the Enlightenment’, in Jeremy Black and Jeremy Gregory (eds), Culture, Politics and Society in Britain, 1660–1800 (Manchester: Manchester University Press, 1991), 154–83. Caroline Hannaway, ‘Environment and Miasmata’, in William F. Bynum and Roy Porter (eds), Companion Encyclopedia of the History of Medicine, 2 vols (London: Routledge, 1993), 1: 292–308; ‘Medicine and Air’, special issue of Vesalius 13(2) (2007); Simon Schaffer, ‘Measuring Virtue; Eudiometry, Enlightenment and Pneumatic Medicine’, in Andrew Cunningham and Roger French (eds), The Medical Enlightenment of the Eighteenth Century (Cambridge: Cambridge University Press, 1990), 281–318; Matthew Eddy, ‘An Adept in Medicine: Rev. Dr. William Laing, Nervous Complaints and the Commodification of Spa Water’, Studies in the History and Philosophy of the Biological and Biomedical Sciences 39 (2008), 1–13; Christopher Hamlin, ‘Chemistry, Medicine, and the Legitimization of English Spas, 1740–1840’, in Roy Porter (ed.), The Medical History of Waters and Spas (London: Wellcome Institute for the History of Medicine, 1990), 67–81. Quoted in Mark Harrison, ‘ “The Tender Frame of Man”: Disease, Climate, and Racial Difference in India and the West Indies, 1760–1860’, Bulletin of the History of Medicine 70 (1996), 68–93, esp. 74–5. See also Karol Kovalovich Weaver, ‘The Enslaved Healers of Eighteenth-Century Saint Domingue’, Bulletin of the History of Medicine 76 (2002), 429–60;

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22.

23.

24.

25. 26.

27.

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Eric T. Jennings, ‘Curing the Colonizers: Highland Hydrotherapy in Guadeloupe’, Social History of Medicine 15(2) (2002), 229–61. Roy Porter, ‘Medicine, the Human Sciences, and the Environment in the Enlightenment’, in Felix Driver and Gillian Rose (eds), Nature and Science: Essays in the History of Geographical Knowledge (Cheltenham: Historical Geography Research Group, 1992), 27–36; Harriet Deacon, ‘The Politics of Medical Topography: Seeking Healthiness at the Cape during the Nineteenth Century’, in Richard Wrigley and George Revill (eds), Pathologies of Travel (Amsterdam/Atlanta: Rodopi, 2000), 279–97; Conevery Bolton Valenčius, ‘Histories of Medical Geography’, in Nicolaas A. Rupke (ed.), Medical Geography in Historical Perspective (London: Wellcome Trust Centre for the History of Medicine, 2000), 3–28; James C. Riley, The Eighteenth-Century Campaign to Avoid Disease (New York: St. Martin’s Press, 1987). Sabine Anagnostou, ‘Jesuits in Spanish America: Contributions to the Exploration of the American Materia Medica’, Pharmacy in History 47(1) (2005), 3–17; Renate Wilson, Pious Traders in Medicine: A German Pharmaceutical Network in Eighteenth-Century North America (University Park: Pennsylvania State University Press, 2000); Alix Cooper, Inventing the Indigenous: Local Knowledge and Natural History in Early Modern Europe (Cambridge: Cambridge University Press, 2007). Anita Guerrini, ‘Archibald Pitcairne and Newtonian Medicine’, Medical History 31(1) (1987), 70–83; Marina Benjamin, ‘Medicine, Morality, and the Politics of Berkeley’s TarWater’, in Cunningham and French (eds), Medical Enlightenment, 165–93; Andrew Cunningham, ‘Sydenham Versus Newton: The Edinburgh Fever Dispute of the 1690s between Andrew Brown and Archibald Pitcairne’, Medical History, suppl. 1 (1981), 71–98; Theodore M. Brown, ‘Medicine in the Shadow of the Principia’, Journal of the History of Ideas 48(4) (1987), 629–49; Sergio Moravia, ‘From Homme Machine to Homme Sensible: Changing Eighteenth-Century Models of Man’s Image’, Journal of the History of Ideas 39(1) (1978), 45–60; J. R. Milton, ‘Locke, Medicine and the Mechanical Philosophy’, British Journal for the History of Philosophy 9(2) (2001), 221–43; Paola Bertucci and Giuliano Pancaldi (eds), Electric Bodies: Episodes in the History of Medical Electricity (Bologna: CIS, 2001); Paola Bertucci, ‘Revealing Sparks: John Wesley and the Religious Utility of Electrical Healing’, British Journal for the History of Science 39(3) (2006), 341–62. Quotation from Francis Schiller, ‘Reverend Wesley, Doctor Marat and their Electric Fire’, Clio Medica 15(3–4) (1981), 159–76, p. 169. Simon Schaffer, ‘Self Evidence’, Critical Inquiry 8 (1992), 328–62; Patricia Fara, Fatal Attraction: Magnetic Mysteries of the Enlightenment (Thriplow: Icon, 2005). Roger French, ‘Sickness and the Soul: Stahl, Hoffmann and Sauvages on Pathology’, in Cunningham and French (eds), Medical Enlightenment, 88–110; Guido Cimino and François Duchesneau, Vitalisms: From Haller to the Cell Theory (Florence: Olschki, 1997); Peter Hanns Reill, Vitalizing Nature in the Enlightenment (Berkeley/London: University of California, 2005). Ursula Backhaus, ‘Johann Heinrich Gottlob von Justi (1717–1771): Health as Part of a State’s Capital Endowment’, in Jürgen Georg Backhaus (ed.), The Beginnings of Political Economy: Johann Heinrich Gottlob von Justi (Boston: Springer, 2009), 171–95; Patrick E. Carroll, ‘Medical Police and the History of Public Health’, Medical History 46(4) (2002), 461–94; George Rosen, From Medical Police to Social Medicine: Essays on the History of Health Care (New York: Science History Publications, 1974); J.-P. Desaive et al., Médécins, climat et épidémies à la fin du XVIIIe siècle (Paris: Mouton, 1972).

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28. Antoinette S. Emch-Dériaz, ‘L’Inoculation Justifiée—Or Was It?’, Eighteenth-Century Life 7(2) (1982), 65–72; Sara Stidstone Gronim, ‘Imagining Inoculation: Smallpox, the Body, and Social Relations of Healing in the Eighteenth Century’, Bulletin of the History of Medicine 80 (2006), 247–68; Adrian Wilson, ‘The Politics of Medical Improvement in Early Hanoverian London’, in Cunningham and French (eds), Medical Enlightenment, 4–39; Andreas-Holger Maehle, ‘The Ethics of Prevention: German Philosophers of the Late Enlightenment on the Morality of Smallpox Inoculation’, in John Woodward and Robert Jütte (eds), Coping with Sickness: Perspectives on Health Care, Past and Present (Sheffield: European Association for the History of Medicine and Health Publications, 1996), 91–114; Andreas-Holger Maehle, ‘Conflicting Attitudes towards Inoculation in Enlightenment Germany’, and Andrea Rusnock, ‘The Weight of Evidence and the Burden of Authority: Case Histories, Medical Statistics, and Smallpox Inoculation’, both in Roy Porter (ed.), Medicine in the Enlightenment (Amsterdam: Rodopi, 1995), 198–222 and 289–315; Andrea Rusnock, Vital Accounts: Quantifying Health and Population in Eighteenth-Century England and France (Cambridge: Cambridge University Press, 2002), Ch. 4. 29. This was also true in the colonies: Weaver, ‘Enslaved Healers’. 30. Ann F. La Berge, ‘The Early Nineteenth-Century French Public Health Movement: The Disciplinary Development and Institutionalization of Hygiène Publique’, Bulletin of the History of Medicine 58 (1984), 363–79; William Coleman, Death is a Social Disease: Public Health and Political Economy in Early Industrial France (Madison: University of Wisconsin Press, 1982). 31. Günter B. Risse, ‘Clinical Instruction in Hospitals: The Boerhaavian Tradition in Leyden, Edinburgh, Vienna and Pavia’, Clio Medica 21 (1987–8), 1–19; idem, Mending Bodies, Saving Souls: A History of Hospitals (New York/Oxford: Oxford University Press, 1999), Chs. 5 and 6; Caroline Hannaway (ed.), ‘Medicine and Religion in Pre-Revolutionary France’, forum in Social History of Medicine 2(3) (1989); Dora B. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris (Baltimore/London: Johns Hopkins University Press, 1993); Colin Jones, The Charitable Imperative: Hospitals and Nursing in Ancien Régime and Revolutionary France (New York: Routledge, 1989); Susan C. Lawrence, Charitable Knowledge: Hospital Pupils and Practitioners in Eighteenth-Century London (New York: Cambridge University Press, 1996); Mary E. Fissell, Patients, Power, and the Poor in Eighteenth-Century Bristol (New York: Cambridge University Press, 1991); Louis S. Greenbaum, ‘Science, Medicine, Religion: Three Views of Health Care in France on the Eve of the French Revolution’, Studies in Eighteenth-Century Culture 10 (1981), 373–91; idem, ‘Nurses and Doctors in Conflict: Piety and Medicine in the Paris Hôtel-Dieu on the Eve of the French Revolution’, Clio Medica 13(3–4) (1979), 247–68. 32. Jewson, ‘Disappearance of the Sick-Man’; Mary E. Fissell, ‘The Disappearance of the Patient’s Narrative and the Invention of Hospital Medicine’, in Roger French and Andrew Wear (eds), British Medicine in an Age of Reform (London/New York: Routledge, 1991), 92–109. 33. Othmar Keel, L’avènement de la médécine clinique moderne en Europe, 1750–1815: Politiques, institutions et savoirs (Montreal: Presses de l’University de Montréal, 2001); Toby Gelfand, ‘Gestation of the Clinic’, Medical History 25 (1981), 169–80; Dora B. Weiner and Michael J. Sauter, ‘The City of Paris and the Rise of Clinical Medicine’, Osiris 18 (2003), 23–42; Erwin Ackerknecht, Medicine at the Paris Hospital, 1794–1848 (Baltimore: Johns Hopkins University Press, 1967); Foucault, Birth of the Clinic; Jacalyn Duffin, ‘Private Practice and Public Research: The Patients of R. T. H. Laennec’, in Ann La Berge and Mordechai

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34.

35. 36. 37.

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Feingold (eds), French Medical Culture in the Nineteenth Century (Atlanta/Amsterdam: Rodopi Press, 1994), 118–48. For studies challenging traditional models of what it meant to be an enlightened medical practitioner, see especially Laurence Brockliss, Calvet’s Web: Enlightenment and the Republic of Letters in Eighteenth-Century France (Oxford: Oxford University Press, 2002), and several essays in Grell and Cunningham (eds), Medicine and Religion. On the Enlightenment, see Dorinda Outram, The Enlightenment (Cambridge: Cambridge University Press, 2005); and Roy Porter, The Enlightenment (Basingstoke: Palgrave, 2001). Roy Porter, Flesh in the Age of Reason (London: Allen Lane, 2003). David M. Vess, Medical Revolution in France, 1789–1796 (Gainesville: University Presses of Florida, 1975). Steven Shapin and Simon Schaffer, Leviathan and the Air-Pump: Hobbes, Boyle and the Experimental Life (Princeton, NJ: Princeton University Press, 1985), 6.

Select Bibliography Brockliss, Laurence, and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997). Cunningham, Andrew, and Roger French (eds), The Medical Enlightenment of the Eighteenth Century (Cambridge: Cambridge University Press, 1990). Duden, Barbara, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany (Cambridge, MA/London: Harvard University Press, 1991). Elmer, Peter, The Healing Arts: Health, Disease and Society in Europe, 1500–1800 (Manchester: Manchester University Press, 2004). Gentilcore, David, Healers and Healing in Early Modern Italy (Manchester: Manchester University Press, 1998). Grell, Ole Peter, and Andrew Cunningham (eds), Medicine and Religion in Enlightenment Europe (Aldershot: Ashgate , 2007). —— , and Robert Jütte (eds), Health Care and Poor Relief in 18th and 19th Century Northern Europe (Aldershot: Ashgate, 2001). —— , and Bernd Roeck (eds), Health Care and Poor Relief in 18th and 19th Century Southern Europe (Aldershot: Ashgate, 2005). Lindemann, Mary, Health and Healing in Eighteenth-Century Germany (Baltimore: Johns Hopkins University Press, 1996). Porter, Dorothy, and Roy Porter, Patient’s Progress: Doctors and Doctoring in EighteenthCentury England (Cambridge: Polity Press, 1989). Porter, Roy, ‘The Eighteenth Century’, in Lawrence I. Conrad et al. (eds), The Western Medical Tradition: 800 b.c. to a.d. 1800 (Cambridge: Cambridge University Press, 1995), 371–475. —— (ed.), Medicine in the Enlightenment (Amsterdam: Rodopi, 1995). —— , and Dorothy Porter, In Sickness and In Health: The British Experience 1650–1850 (London: Fourth Estate, 1988).

chapter 6

m edici n e a n d moder n it y roger c ooter

Neither ‘medicine in modernity’ nor ‘modernity in medicine’ has been well served by historians. In fact, they have hardly been served at all. While historians have written on many aspects of modern medicine—therapeutic shifts, politics, culture, economics, ethical issues, and so on—none have attempted to set medicine in the framework of any generalized understanding of modernity. Modernity is usually assumed to be more or less synonymous with ‘the modern’, and is often muddled with notions of ‘modernization’ and ‘modernism’. Even in histories of medicine with ‘modernity’ in their title it is rare to find specific reference to the concept of modernity, let alone any wrestling with the notion. At best, as the author of Medicine and Modernism (2008) submits: ‘Modernity’ and ‘modernization’ are terms that historians use to refer to the interrelated series of economic, social, and political transformations that occurred in western societies during the period of the long nineteenth century. Urbanization, industrialization, and the spread of market capitalism were among the most salient features of these changes.1

By this reckoning, modernity is an unproblematic socioeconomic process or material force specific to a historical period. Its dimensions are temporal and spatial, its effects palpable. It is not, as Foucault once suggested, an ‘attitude’ struggling perhaps against a ‘counter-modernity’.2 Nor is it, as Weber understood it, and I will elaborate below, a particular apprehension and organization of the world. Nor can it be, as postmodernists would have it, an intellectual construct, idealization, or ‘project’ subject to different kinds of enthusiasms and critiques over time—another of the subjects to which we will turn. The nearest that historians have come to any critical analysis of the concept in relation to medicine is in the few studies that incorporate specific aspects of corporeality in broader sociocultural and intellectual histories of modernity. A fine example is Anson Rabinbach’s history of the transformation of managerial perceptions of labour in Europe between the mid-nineteenth and mid-twentieth centuries. Subtitled ‘Energy, Fatigue and the Origins of

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Modernity’, Rabinbach’s study examines the work of psychologists and physiologists who redefined the human body as a ‘human motor’ capable of generating measurable and regulable amounts of physical and mental work.3 Another example of this type of partial engagement with medicine is Wolfgang Schivelbusch’s history of the introduction of the railway—one of the most vivid symbols of modernity and a powerful stimulus to medical debate over the effects of modern life on the human organism.4 Railway accidents, or simply the unprecedented speed and physical jarring of trains, were commonly identified as the precipitating causes of a condition known as ‘railway spine’. Interestingly, this condition figures prominently in one of the few literatures to engage explicitly with medicine and modernity, that on the history of psychology and psychiatry, though it must be said that, in its concentration on subjective sensibilities, this literature often has more in common with literary analysis of modernism as opposed to more historical or sociological investigations of modernity. Some sociologists of medicine have brought aspects of modernity into their purview (while generally evading discussion of modernity itself). This is especially the case among those in the 1980s and 1990s who sought to show how medical views of the body served the aims of social surveillance and administrative regulation and self-regulation. So doing, these writers assimilated medicine to narratives of modernity linked to ‘the establishment of disciplines, knowledge, and technologies that serve to proffer advice on how individuals should conduct themselves’.5 Their work stressed the importance of medical knowledge and the ‘normalization’ of health regimes that discipline individuals into the larger aims of modern society. However, although they commented lucidly on the regimentation of the body, as well as on medical activities that contributed to the setting and policing of administrative norms and standards, they offered no detailed accounts of how, if at all, such conditions came to prevail. They proffered only grand assumptions that, at best, were parasitic on medical history. Sadly, however, historians have not taken up these themes for themselves. Nor has there been any serious historical reflection on the phenomenon of modernization in relation to medicine. Modernization is usually associated with political planning on the part of developing nation-states, with programmes to eradicate disease or to build hospitals and clinics and the like often regarded as fundamental to the development process. Invariably regarded as a universal ‘good’ and sometimes even juxtaposed to the evils of ‘militarization’, medical modernization is usually discussed without reference either to ‘medicalization’ or to the biopolitics of population manipulation for economic or military advantage. Unsurprisingly, this literature never acknowledges that the notion of ‘development’ is itself an instance of biological discourse. This chapter delineates the integral place of medicine and corporeal thought in the structuring and sustaining of ‘the modernist project’. To a degree, it is predicated on an understanding of the transcendence of modernity in ‘postmodernity’, the basis for thinking that will be made apparent in the latter part of this chapter. Along the way we will also touch briefly on the place of modernism in medicine. First, though, a brief survey of ‘the modern’ in medicine is in order, if only to banish any idea that modernity’s discussion in medicine before the ‘postmodern turn’ could only be retrospective and anachronistic.

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The modern in medicine ‘The modern’ in what we now call ‘modern thought’ was from its very beginnings in the sixteenth and seventeenth centuries also an actors’ category. Not least important among the contemporary actors involved were those at the cutting edge of the delineation of the human body, most notably Andreas Vesalius (1514–64) and William Harvey (1578–1657). In what was to become known in the late seventeenth century as the debate between the ‘Ancients’ and the ‘Moderns’, Vesalius’s stunning anatomical depictions and Harvey’s description of the circulation of blood were located on the side of the ‘Moderns’—on the side, that is, of those advocating experimental method and opposed to Aristotelianism, scholasticism, and the dogmatic teaching methods of the ‘Ancients’. Ultimately, their work would come to be seen as promoting ‘modern’ scientific naturalism, empiricism, objectivity, and rationality. But neither Vesalius nor Harvey was keen to have their work promoted as such. Vesalius, a Renaissance humanist, did not regard himself as a figure of modernity breaking new ground. Ostensibly, his interest was in correcting and improving the ancient wisdom and authority of Galen, a new addition of whose writings he prepared for publication. Harvey, for his part, retained a deep faith in the methods of scholasticism at the same time that he forwarded a mechanistic view of the body that (thanks mainly to the attention paid it by the French philosopher René Descartes) was to become integral to modern rationalist thought. Then, as now, new systems of knowledge and methods of inquiry were not regarded as necessarily supplanting older ones. Nor were they cherished for having the capacity to function morally, insinuating the superiority of one method over another. The word ‘modern’, to the limited extent it was used in the seventeenth century, meant ‘of now’ as distinct from ‘in the past’; it did not equate to our use of it as synonymous with ‘good’ or ‘better’. It was not until the twentieth century that the word became ‘virtually equivalent to improved, or satisfactory or efficient . . . to indicate something unquestionably favourable or desirable’, as the late Raymond Williams pointed out in his succinct analysis of it.6 With respect to medicine, it was not really until the 1930s—reflected often in hospital architecture—and more especially in the 1940s with the advent of penicillin (when medicine came to be widely regarded as capable of doing no harm) that the adjective ‘modern’ ceased to sound derogatory. However, that was only for a brief while: after the thalidomide tragedy of the early 1960s negative connotations returned, with ‘modern medicine’ becoming something of a source of mockery vis-à-vis the perceived merits (sociopolitical as much as therapeutic) of alternative types of healing. While ‘progress’ from the eighteenth century was increasingly held to be a good thing, and rational and scientific medicine a way to bring it about, modernity was a different matter. Increasingly, it came to be associated with fearful sources of moral corruption and with the decline of civilization. It was in these terms that it came to be embodied in the mid-nineteenthcentury concepts of ‘neurasthenia’ and ‘degeneration’. Neurasthenia, famously elaborated by the New York neurologist and electrotherapist George Miller Beard (1839–83), was held to be a consequence of the unprecedented demands

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on the nervous system imposed by modern living. ‘Steam power, the periodical press, the telegraph, the sciences, and the mental activity of women’, Beard claimed, were among the causes of this enervating condition, the sufferers from which were mostly white, educated, middle-class urbanites engaged in brain work.7 Neurasthenia was thus both a medical theory and a social critique of modernity. So, too, was the idea of ‘degeneration’ with which it was closely associated. Articulated in the shadow of evolutionary naturalism to refer to a ‘morbid change in the structure of parts, . . . [or] a substitution of a lower for a higher form of structure’,8 the idea of degeneration found particular favour in psychiatry and in an overtly medicalized version of criminal anthropology. Unlike neurasthenia, however, which harkened to the evils of ‘modern’ living on individual constitutions, degenerationism pathologized society as a whole. Although there were many motives to, and messages within, its expression, implicit to almost all of them was a view of society ‘as a body which could grow and develop . . . suffer illness, crisis, perhaps even death’.9 Whether witnessed through the spectre of overwhelming hoards of ‘unwashed’ immigrants, criminals, genetically predisposed alcoholics, ‘mental defectives’, ‘racial degenerates’, or simply the stunted and overbreeding, slum-dwelling, and feckless ‘underclass’, those who articulated degenerationism feared loss of control over the governance of modern society, a civilization they sometimes imagined in terms of a driverless locomotive hurtling through the night. Yet, as new-fangled theories, neurasthenia and degenerationism were themselves signs of modernity in medicine. Dialectically, they cut new social paths in medical thinking at the same time as they established new medicalized ways of thinking about society and individual identity. The same explicitly modernist signature can also be assigned to more mundane developments in medicine—above all, perhaps, to the rise of laboratory medicine. But this attribution is not because laboratory medicine ‘led to’ or ‘made’ modern medicine, as is commonly proclaimed. Rather, it is because laboratory medicine was implicated in challenging conventional modes of thought both within medicine and without. Within medicine, it challenged the prestige of the ‘art’ of bedside medicine over the alleged abstract, reductive methods of ‘science’. Thus laboratory medicine could emerge, as in mid-nineteenth-century Russia, as ‘a symbol of modernity and scientific method’.10 However, it could also signify challenges to prevailing sociocultural norms, as when (again in Russia) its exponents wielded it as a progressive materialist force destructive of autocratic religiosity as much as of absolutist grand theories of medical knowledge. In other words, laboratory medicine and methods could be ‘modernist’ not because of what they were in and of themselves, or because of the historical narratives into which they could come to fit, but rather, because of what they stood for iconoclastically.

Weberian modernity It was not, however, with smashing ‘backward’ or traditional values in medicine and society that the pioneer sociologist Max Weber (1864–1920) was concerned when he elaborated the characteristics of modernity. Writing in the years around the First World

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War, Weber identified a constellation of social processes and forms that he saw crystallizing about him, and which he perceived as among the ‘disenchanting’ features of latenineteenth-century industrial society. These included the growth, differentiation, and integration of bureaucracy and other organizational and managerial systems, the standardization, centralization, and routinization of administrative action, and the employment of experts to define and order such systems. Unification and uniformity, Weber thought, were fundamental aspects of ‘modern’ as opposed to ‘traditional’ society. Whereas traditional social systems operated through diverse forms of social interaction and bonding, modern ones aspired to conformity through the imposition of bureaucratic planning and administration. Underlying this, as indicated by Weber’s designation of such a society as ‘rational’, was a form of calculative and evaluative logic that both legitimized and advanced the extension of bureaucratic structures into ever-more intimate areas of social life.11 Weber also appreciated that an important expression of this rationality was the development and application of scientific and technical productions that further transformed older social legitimations and ways of knowing. In medicine many of these features were becoming well entrenched by the time Weber came to write on modernity. Indeed, it may not be incidental to his interest in this subject that during the First World War he was delegated to oversee an area of hospital administration. However, long before then, in Germany and above all in the USA, reforms in the administration of hospitals and clinics had been prosecuted in terms that Weber would later treat synthetically for society as a whole. In places such as the Mayo Clinic (established in remote Rochester, Minnesota, in the 1890s) the features increasingly associated with ‘scientific management’ in industry—specialized divisions of labour, time management, record-keeping, cost accounting, and so on—were finding their place in medical and surgical practice.12 (Appropriately, it was in the Mayo that Frederick Taylor (1856–1915), the pioneer of scientific management, came to his end, his notorious stopwatch for time-and-motion calibrations tightly clutched.) Also in the air by the late nineteenth century were suggestions for turning hospital outpatient departments into (mini-Mayo-like) polyclinics with specialist functions. Medical philanthropy, too, submitted to centralized rationalization and coordination. As in hospital outpatient departments, allegedly wasteful and inefficient duplications of philanthropic effort and expense were brought to heel by bodies such as the UK’s Charity Organization Society. Older face-to-face social relations in medical welfare disappeared. As in medical practice generally, the tendency was to corporate systems of mass health care animated more by managerial concerns with collective efficiency than by the pursuit of personalized patronage or individual competition among practitioners. Thus was calculative thought brought to bear in medicine and prosecuted through it. In the name of efficiency the social and intellectual underpinnings of medical care and medical philanthropy were remade. In part this was directly attributable to the links that were increasingly forged towards the end of the nineteenth century between medicine and industry and business. Industrialists took a growing interest in running hospitals as a means to maintain the moral and physical health of their workers. At the same time, the governors of hospitals invited in a new breed of managers from the world of

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finance and business. These were persons who stressed the economic advantages of applying business principles to medical charity. Among other things they became responsible for introducing systems of uniform accounting. They also founded associations to enforce similar economies across groups of hospitals in order to eliminate what they regarded as wasteful duplication of services. Doctors, too, became caught up in this process and began to look for ways of improving the efficiency and productivity of their practices. This was particularly evident in surgery, where new and more sophisticated operative procedures lent themselves to new forms of work management. Hence, by the late nineteenth century, to maintain ‘steadfast business-like habits’ in surgery was something to be proud of. Simultaneously, the term ‘the firm’ became the laudable characterization of a new hierarchical organization of junior doctors working under a senior hospital surgeon.13 That considerable efficiency savings could be secured by such ‘rational’ reorganizations of clinical work was abundantly clear. In Liverpool during the early 1900s, the budding orthopaedic surgeon Robert Jones (1857–1933) reorganized his clinic at the Royal Southern Hospital into a showpiece of managerial efficiency. It enabled him to handle staggeringly heavy caseloads of injured dockers. As one of his colleagues proudly recalled: [Jones] got through an immensity of work . . . rendered possible by the systematic preparation of the patients and by the work of the anaesthetists who had each successive patient ready by the time the operation on its predecessor had been completed . . . He had round him a number of helpers, some of them medical men glad of the opportunity to get experience, others consisting of a nursing staff trained in the application of splints and plaster-of-paris . . . other workers who had received some training kept an eye on the home conditions of the patients with reference to their feeding and regular attendance for massage, or other special treatment, at the Hospital.14

Such observations were echoed by dozens of visitors to Jones’s clinic, including William Mayo (1861–1939) of the Mayo Clinic. It was as the epitome of modernity in medicine that they hailed Jones’s meticulous delegation of labour and the enormous increase in productivity it made possible. Jones’s case is extreme, of course, but it serves to exemplify the organizational logic of efficiency being pursued with more or less enthusiasm in clinical medicine throughout the Western world by the 1900s. This is not to suggest that there was not also opposition and resistance to these managerial innovations in the culture of medical practice. There was, particularly in hospital practice where the move towards specialization—and hence towards technical efficiency—tended to be restricted by countervailing pressures within the social relations of elite medicine. Many hospital doctors were deeply ambivalent and even hostile to the emergence of specialization and the changes it implied in the social relations of hospital work. Their concerns related mainly to the impact that such changes would have on existing patterns of elite private practice. This was especially so in London, where the elite consisted of generalist consultants attached to prestigious voluntary hospitals

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where they gave their services free in order to build up lucrative private practices. Independent specialist clinics established by enterprising young doctors were condemned by this elite, who saw their cozy and exclusive world thereby threatened. Specialization, they argued, smacked of commercial practice and vulgar American-like free-market competition; instead of relying on established networks of patronage, it involved appeals to public credulity that came close to quackery. It was for this reason that British members of the emergent league of international superstar surgical specialists insisted on maintaining generalist status while nevertheless performing little other than specialist work. Robert Jones, for instance, was described by William Mayo in 1907 as ‘that type of specialist who had been, and continues to be, a general surgeon, but has been forced by the large amount of work to become a specialist’.15 Mayo swallowed the line. Well into the interwar period much of the practice and institutionalization of medicine remained within a culture of patronage and elite philanthropy. Yet at the same time medicine operated within a culture of corporate business. Almost inevitably the balance tilted to the latter. Not the least of the reasons for this was that governments, too, were increasingly driven by the ideology of efficiency. They were keen to apply it, not just in the area of state medicine (primarily public health, poor law, and the military), but also, biopolitically, to the production and reproduction of bodies ‘fit’ for efficient military and industrial use. The national efficiency movement of the turn of the century embraced just this, channeling unprecedented interest in the health of populations, and the health of mothers and children in particular. National health insurance programmes in Britain and Western Europe encouraged much the same. And so too, above all, did war.

War, medicine, and modernity That modern wars tend to corporatism and administrative ways of knowing and acting was fully appreciated by Weber. He saw the characteristics of bureaucratic modernity epitomized in the army: the concentration of administration in the hands of masters; tight hierarchy and strict subordination; the pursuit of technical mastery, speed, precision, unambiguity, discretion, secrecy; and, above all, the ‘discharge of business according to calculable rules and “without regard of persons” ’.16 As such, it could be said of modern wars (from this Weberian perspective) that they epitomized ‘the rationalization of slaughter’.17 The same kinds of rationalization deemed necessary for the conduct of large-scale business, philanthropy, and industry came to seem essential for the efficient operation of mass armies. Weber was inclined to see such processes as actually originating in the military: ‘The discipline of the army gives birth to all discipline,’ he declared, disdainful of the resulting ‘rage of order’ around him and the expansion of military and civil discipline.18 However, others were not so inclined: the French poet and philosopher Paul Valéry (1871–1945), for example, declared the military command structure as the epitome and ‘ideal’ of modern socioeconomic organization.19

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Most historians tend to trace the links between war, medicine and modernity to the American Civil War of 1861–5, and more especially to the Franco-Prussian War of 1870–71—though in these instances modernity is often equated simply with industrialization rather than with the characteristics of management rooted in notions of efficacy. The American Civil War was remarkable not only for its use of railways, steamships, early machine-guns, and so on, but for its mass mobilization of ‘citizen soldiers’ and its routinization and standardization of administrative procedures and technologies. Among the latter were techniques for gathering and abstracting information about populations in general, and the bodies of soldiers in particular—techniques of surveillance and regulation that aimed at greater control and efficiency of military manpower. The Franco-Prussian War carried these developments further, rendering the organization of war comparable to that of the scientifically managed factory, or, as Daniel Pick has provocatively suggested, to the systematization of slaughter and butchery that took place in the new Parisian abattoirs of the 1860s.20 As in the rationalized slaughterhouse geared to maximum production and profit, so in warfare: specialized divisions of labour, uniformity, and centralized inspection of work discipline became the hallmarks of a new and more systematic organization of concerted human endeavour. The waging of war and the killing of enemy soldiers became an efficiency-driven mechanized industrial process. Although rationalizations of medical procedures and practices to enable military efficiency can be traced at least as far back as the Napoleonic Wars, it was above all during the First World War (1914–18) that these processes became manifest. Like the late Victorian city with its expanding system of integrated public utilities, the field of battle was now networked not only by railways and telegraphic lines of communication, but also by specialized and coordinated emergency medical services. The need for these was rendered all the more urgent by the ever-growing shortage of fit recruits after their haemorrhage during the first years of the war. Thus out of mounting concerns with efficiency and wastage, the medical repair of soldiers became a calculative part of military strategy. By mid-1915 a system was in place that, even if it did not always function as smoothly as intended, was at least well devised. There were clear lines of communication down a hierarchical chain of command; an efficient division of labour within and between stretcher-bearers, casualty clearing stations, and base hospitals; segregation and transportation of different types of injuries; the standardization of supplies and clinical procedures; uniformity in the surgical control over patients; and continuity in patientcare and after-care. Like scientific management in factories, this integrated regulatory system was designed to process its goods as efficiently and economically as possible. Elaborate systems of uniform record cards were devised to establish, control, and monitor quality, and ‘team work’ (a term introduced into medicine during the war) became the order of the day. There were even attempts directly to apply Taylorite time-andmotion principles to the treatment of fractures. Meanwhile, ‘the physiology of industrial organization’ was applied to the re-employment of the war-disabled. Physiology—a metaphor for integrated system—increasingly structured the work and the workplace of doctors and patients alike, while engineering principles came to be applied to the

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reconstruction of the physiological efficiency of the human body as a ‘perfect machine’. In Germany the accomplishment of simulating locomotor functions through dozens of different types of artificial arms and legs is still hailed by historians as ‘medicine’s most dramatic achievement during the war’.21 The rationalization or ‘modernization’ of medicine during the First World War was also driven by efficiency-minded young turks like Robert Jones. Since Jones’s expertise in the handling of trauma had been shaped and structured by the economic rationalizations of the late Victorian and Edwardian period, there is nothing odd in the fact that his clinical methods should have become favoured in a context in which an increasing proportion of the army’s labour force was becoming disabled, and when concerns with efficiency and economy in the military were becoming analogous to those of modern industry. In effect, by 1916, the war had become a socioeconomic context in which, as the value of labour rose in proportion to the fall in its supply, the state (as employer) had come to perceive medical expertise as crucial to its manpower problem. It is no coincidence, therefore, that besides orthopaedics, the other areas of medicine that were to contribute most to this ‘industrial strategy’ were cardiology and neurology—specialisms that also attracted practitioners given to physiologically mediated ‘economic’ understandings of the ‘human motor’. In effect, physiological or functionalist comprehensions of the body provided a metaphor for the administration of integrated, and therefore cost-effective, medical services. This is not the place to discuss how such specialisms fared after the First World War. Nor is there need to pause over the history of the local, national, and international politics involved in the aspirations to realize this managerial idealization in the fabric of civilian medical organization, the success of which in many cases increasingly blurred welfare and warfare distinctions in medical care. These stories and those of the contributions of the Second World War can be found elsewhere.22 Suffice it to say here that the two World Wars vastly extended the forms and processes of modernity as understood by Weber: the size of bureaucracies, the number of managers, the extent of the integration of civilian and military spheres, and the scale and sophistication of the mass manufacture of armaments and the routinized treatment of their effects on human flesh. Although Weber himself had no particular interest in how the body was rationalized through war (through the military’s ever-greater adoption of reductive mono-causal scientific medicine), historians have no need to depart from his understanding of the making of the modern world to comprehend how the body became an object of modernity as much as medical practice did (for the most part seamlessly). For the military, scientific medicine was attractive as a cheap means for dealing with the unproductive sick, because once all bodies could be understood as essentially the same in disease, they could be dealt with in standardized ways, like products in a factory or soldiers in a platoon. What was good for one soldier was good for all, never mind that there were few cures before the 1940s. Inoculations against smallpox and typhoid and the anti-toxin for diphtheria had proven the worth of ‘scientific’ medicine to the military by the late nineteenth century, and the further discovery (made during the First World War) of the causal connection between the body louse and typhus was added confirmation.

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The high noon of this modernity in medicine was during and after the Second World War when the Western body was standardized, normativized, and routinized to a degree never experienced before in history. Individual metabolisms and physiologies, for example, now surrendered to ideal body weights.23 It was not really until AIDS in the early 1980s that there began some departure from the reductive ‘mass medicine’ of the ‘golden age of medicine’ in which all bodies were construed as essentially the same in terms of their response to disease agents and would-be countervailing ‘magic bullets’. Privatization of health care and the emphasis on individual consumption of health products hastened this departure. Although there was to be no return to pre-modern understandings of entirely individualized therapeutics, biomedicine’s message of universality became less strident in the face of multifactoral explanations for various conditions and diseases.

Modernism and the advent of postmodernity Weber’s account of the making of the modern ‘rational’ world readily permits comprehending medicine in modernity (and modernity in medicine) embedded in concrete socioeconomic realities. What it does not permit is seeing Weber’s analysis of modernity as itself a product of modernity—as an intellectual assemblage born within, and seeking to explain, the culture of modernity. For this one needs a postmodern vantage, or that of the poststructuralist transcendence of the socially interconnected world marching its way to bureaucratic rationality. For postmodernists living in post-Cold War times, the world did not appear in the unified, integrated, and standardized way that Weber depicted it; rather, it was experienced as deeply fragmented, fractured, and pluralistic. If modernity was about making the world whole through universal meanings and logics, postmodernity and poststructuralism were about exposing how we came to think that way in the first place, and what purpose it served. Weber’s analysis, like that by Marx or that on the nature of ‘human nature’ by Freud, came to be perceived by postmodernists as quintessentially modernist in that it provided a historical meta-narrative that cohered a ‘rational’ understanding of the world and its inhabitants. By the late twentieth century, postmodernists felt, modernity was an out-of-date servant to a reactionary narrative master that could serve only to cloud understanding of the contemporary (postmodern) world. Postmodernism as a literary and linguistic intellectual movement may not have been essential in alerting the Western world to the eclipse of former social and political coherences (and to the type of industrial manufacture that went with them). Wars, too, were no longer mobilizations of the masses. By the time the arch-neoliberal politician Prime Minister Margaret Thatcher (1925–) appeared to be echoing postmodernists in her proclamation that ‘there is no such thing as society’—fondly hoping to fuel an individualist psychology and consumerism—there was already a widespread feeling among academics of a ‘loss of political appetite for the old frameworks of social analysis’.24 However, the

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literary postmodern movement was nevertheless helpful in providing a perspective on modernity (now often ‘modernities’)25 as a ‘project’ that had created certain configurations of reality and rationality. Among these were the narratives of racism and nationalism, and the master narratives of socialism, the Enlightenment, progress and, not least, modernity itself. Although the latter came in for surprisingly little systematic analysis in postmodernist writing, postmodernists did make clear that all former critiques of modernity were incomplete because, to varying degrees, they remained wedded to the discourse of modernity—in particular, to the categories and foundational assumptions of modern rationalist thought. Concepts within the discourse of modernity, such as ‘society’, ‘class’, and ‘the individual’, remained epistemologically autonomous, hence seemingly objective, natural, impartial, and indisputable. In other words, the discourse of modernity ‘essentialized’ concepts and categories that were in fact historically created linguistic products that necessarily served the exigencies of political power and political order. The postmodern move was to problematize them and hence undercut their appeal as universalist and historically transcendent categories. Rationality itself as commonly experienced, and any belief in ‘scientific rationality’ as the alpha and omega of modernity, thus came to be understood as cultural constructs. Overall, what postmodern scholars established was that modernity was not an epoch or a branch of ‘modernization’, but a discourse or a way of talking and conceptualizing ‘reality’ that served to make up that reality through those very acts of speech and thought. Interestingly, if somewhat confusingly, it was mainly in literary studies of modernism in relation to the First World War that postmodern ways of thinking began to penetrate historical practice. These studies were not inspired by Weber. They spoke to an aesthetic ‘birth of the modern’, discerning it in such expressions of high culture as the music of Stravinsky, the paintings of Munch and the Dadaists, and the poetry of Sassoon, Brooke, and Eliot. In the literary and cultural histories of Modris Eksteins, Samuel Hynes, and Paul Fussell, for example, ‘modernism’—understood to be ‘the principal urge of our time’26—is born in the course of the First World War and is held to sever the cord between present and past ‘beliefs, values and imagination’.27 It finds its voice in the articulation of a uniquely ‘modern memory’ that allegedly has no knowledge of events before the carnage of Flanders.28 Given this literature’s interest in psychologies of remembering and identity within the shared social experiences of the First World War, it is not surprising that discussions of shell shock were central to much of it. However, unlike histories of medicine and the processes of medical specialization during the War, this literature operates in a sphere quite unconnected to the historical and sociological examination of modernity. Modernity links here, not to mass X-ray screening, pedascopes, and germ-conquering linoleum, nor much even to jazz, scientific socialism, airplanes, and escalators; rather, it rests solely in the literary expressions of a few gifted individuals, or in the tensions and contradictions between different sets of social assumptions and experiences. Contradiction and ambiguity are of course the stuff of literature, but in the ‘real’ material world individuals habitually move between different and often inconsistent social institutions and logics with unthinking ease. The way in which present-day historians move between the logics of modernity and postmodernity might be a case in point, never mind the example of Andreas Vesalius and

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William Harvey in the sixteenth and seventeenth centuries with one foot in the camp of the Ancients and the other in that of the Moderns. In any event, it would be wrong to conclude that modernist Weberian sociological accounts of modernity and literary proto-postmodern accounts of modernism must necessarily be at odds. Literary modernism might be paralleled with early-twentiethcentury architectural modernism, the point of which was to replace the fusty ‘irrational’ designs of the past with clean and simple ultra-new ‘cosmopolitan’ lines. As made clear in a recent study of an internationally famous fracture clinic in interwar Vienna, the pursuit of scientific management in clinical medicine could easily harmonize with, and contribute to, such modernist aesthetics.29 If historical illustrations of this kind are far and few between it is only because, overall, literary and aesthetic studies have tended to the postmodern view that Weberian modernity is a species of modernist production and therefore unsuitable for postmodern analysis. A victim of new intellectual times, Weber’s view of the socioeconomic realities of his time has become less and less interesting in the face of the anxieties of postmodern authors—pertinently, anxieties mostly around the body.

Postmodern bodies, modernist history As with the debate between the Moderns and the Ancients in the late seventeenth century, that between postmodernists and modernists in the late twentieth century had its origins in French literary culture. However, it soon transcended those national and disciplinary boundaries, ultimately coming to penetrate and rupture almost every field of Western intellectual inquiry, just as rationalist modern thought had done previously. Among its many effects—crucial here—was the elevation of the body to a privileged site for the analysis of modernity. This was not accomplished in intellectual isolation; it required, too, the narcissistic culture that prioritized the body—a culture in which concerns over health and fitness, dieting, weight loss, obesity, personal grooming, drugs for sexual and mental ‘enhancement’, tattoos, body piercing, cosmetic surgery, gender reassignment, organ transplantation, and so on, left the sociopolitical preoccupations of the 1960s and 1970s far behind. AIDS, to be sure, was not unimportant in opening the floodgates to this corporeal attentiveness in the 1980s and 1990s. But bodies had also become big business, the focal point of an expansive and internationally expanding consumer culture. While bodies had always been important in human existence, not least for social ordering, by the late twentieth century they had become, in the West above all, ‘the privileged site of experiments with the self ’.30 Today, few historians, and even fewer cultural analysts, would dispute that the history of the body constitutes an important chapter in the contemporary history of thought. Corporeality and pathology have become obligatory points of passage in the study of society and culture. Very largely this ‘somatic turn’ is due to the influence of Michel Foucault (1926–84), one of the towering intellectuals of the second half of the twentieth century. From the 1960s, around medical knowledge and medical institutions especially,

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Foucault articulated a concept of power (and methods for investigating it) that centred on the micro-management of individual human bodies through various disciplinary techniques. Power did not derive simply through social and political institutions, he argued, nor did it function merely by coercion. Rather, it operated through, and was inscribed upon, the body, which was ‘directly involved in a political field; power relations have an immediate hold upon it; they invest it, mark it, train it, torture it, force it to carry out tasks, to perform ceremonies, to emit signs’.31 The body, Foucault and his interlocutors insisted, is ‘where power has historically assumed its most monstrous and its most liberatory incarnations’.32 In corporealizing power, Foucault simultaneously de-centred sociological notions of medical power and challenged essentialist reductions of life to biology. Medical power was not to be understood instrumentally, in terms of state initiatives, nor was it to be found simply in the history of doctors and their institutions. Rather, it was in the implicit rules of disciplinary discourses that worked on the bodies of individuals. In not being regarded as ‘sovereign’, or unitary or centralized, power was not to be conceived as instrumentally wielded by obvious agents. Instead, it was to be understood as embedded everywhere in the social body of health that since the eighteenth century has made up our ‘biosocial’ or somatic—body-centred—culture. Hence Foucault’s increasing use of biopower (and attendant biopolitics) to refer to knowledge-producing processes and strategies through which institutional practices come to define, measure, categorize, and construct the body and, increasingly, shape all experience, meaning, and understanding of life. Many discourse analysts turned to the body and body history to explore Foucault’s notion of the power/knowledge nexus, and to contribute to his wider project to historicize reason and explore ‘how men govern themselves and others by the production of truth’.33 The effect was the somatic impregnation of the ‘literary turn’. Before long, scholars were revealing how the categories of ‘the body’ and ‘history’ mirrored each other: the invention of modern history as a discipline seeking to objectify the past coincided with the invention of modern medicine as an enterprise seeking to objectify the body.34 History and modern medicine worked in tandem; both could be understood as products of the modernist project that invented the idea of the disciplines in the first place. It is hardly surprising, therefore, that historians, and historians of medicine in particular, initially shied away from postmodern discourse analysis, since they themselves were increasingly to be seen as a part of the object of study (a part of the problem), inside the project of modernity. To some historians it came to seem that their craft was ‘a lost domain’.35 Others pronounced it hopelessly and haplessly tied to a critically useless epistemological frame that failed to challenge the discursive and political nature of most of the key concepts that it deployed, such as ‘experience’.36 Not only could historians be charged with naïve empiricism and with what the arch critic of modernity, Robert Musil, once referred to as ‘a dipsomania for the factual’,37 but their writings could be held to be inherently modernist in as much as they attempted to impose narratives on the past, and through them, foster (mis-)understandings of the present. In other words, modern history (linear and causal for the most part) could be accused of serving the same logic as the modern body, or the body in modernity.

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By the turn of the millennium, however, there were many signs that historians were increasingly accommodating themselves to postmodern tropes—not least through the deluge of books and articles they were writing with ‘the body’ in their titles. More attentive to discourse and to the historical ontology of concepts, they now frequently adopted less narrative, more ethnographic approaches. Yet this shift was no sooner commenced than the tide to which it was responding began radically to turn. Serious counteractions to postmodernism began to emerge, some of them explicitly seeking to revive ‘an agenda for history [that] was more common in the past than it is today’.38 Among these were contributions to the new ‘global history’ that pursued the inherently unificatory concept of the globe in a deliberately anti-postmodern fashion. In train with this is the now prevalent ‘neurological turn’ in history-writing, in some cases by those formerly at the cutting edge of social constructivist and literary postmodernist approaches. Presumably, this move is one to ‘relevance’ in our ‘neural times’, but in the innocent hands of historians with little or no expertise in the history of science and medicine it is politically fraught. As in the medievalist Daniel Lord Smail’s On Deep History and the Brain (2008), scientific results come to be used as tools to write about the past, in ignorance of the fact that the tools themselves are historical products. The result is not merely an outcrop of biological essentialism and biological reductionism within new neurohistorical meta-narratives, but also something new and entirely worthless from the point of view of sociocultural analysis: biological history. Neither the authors of neurohistory nor their reviewers seem aware of it. If the voice of a leading sociologist of science is anything to go by, Smail’s book ‘is the single most important work of historiography in English since [the postmodernist’s] Hayden White’s Metahistory’.39 Far, then, from history-writing becoming more postmodern, the bridges are rapidly being burnt to those beginnings, tentative and very recent though they are. In an age of ‘greedy reductionism’ and ‘biological citizenship’,40 critical thought itself appears to be in peril of scientization, with the crucial divide between the sciences and the humanities at a point of dangerous dissolution. Whether there is any advantage in styling this a return to modernity may be a moot point. While the construction of humans as ‘cerebral subjects’ is something that historians have long associated with the processes of modernity,41 it would seem more important at the current juncture to monitor the cultural course of the ‘neuro tide’ and remain alert to the political pull of its undercurrents.

Conclusion ‘Medicine and modernity’ rolls off the tongue with deceptive ease. As we have seen, its pursuit in the history and historiography of medicine demands much more than simply tracing innovations, and far more than merely challenging vague assignments of the label to scientific institutions and authorities formalizing the status of health and disease. To begin with, the concept of modernity, or ‘the idea that its newness is a new kind of newness’,42 has been a major source of acrimony, anxiety, and debate (in medicine and elsewhere) since at least the sixteenth century. For another thing, conceptions of the

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body and theories of mind have clearly been integral to the concept’s career. As the midnineteenth-century social critiques of modernity embedded in neurasthenia and degenerationism gave flesh to the notion, so too did postmodernism through its heuristic interdependency with modernity in general, and through its somatic turn in particular. Sandwiched in between was Weber’s unificatory notion of modernity as administrative rationality. Although Weber did not explicate this in terms of the socioeconomic dynamics of medicine from the late nineteenth century, it was there, as we have seen, that the processes were in many ways epitomized, especially during wartime. Thus, not only the history of medicine, but the history of modern thought depends upon an understanding of modernity in medicine and medicine in modernity. In the face of the ‘neural turn’ in history threatening not only the gains of postmodern and poststructural critical insight on, and approaches to, modernity, but also the humanistic purpose of history, the need for this understanding is becoming ever greater.

Acknowledgements This chapter leans heavily on material I have previously published, some of it, in the first sections, co-authored with Steve Sturdy, and, in the latter sections, with Claudia Stein. I am deeply grateful to both colleagues, as well as to all those, over the years, who have offered constructive criticism. As ever, I remain hugely indebted to the Wellcome Trust for its generous support.

Notes 1. L. S. Jacyna, Medicine and Modernism: A Biography of Sir Henry Head (London: Pickering and Chatto, 2008), 4. 2. Michel Foucault, ‘What is Enlightenment?’, in Paul Rabinow and Nikolas Rose (eds), The Essential Foucault (New York: The New Press, 2003), 48. 3. A. Rabinbach, The Human Motor: Energy, Fatigue and the Origins of Modernity (Berkeley: University of California Press, 1992). 4. W. Schivelbusch, The Railway Journey: The Industrialization of Time and Space in the Nineteenth Century (Leamington Spa: Berg, 1977). 5. Deborah Lupton, The Imperative of Health: Public Health and the Regulated Body (London: Sage, 1995), 9. 6. R. Williams, ‘Modern’, in his Keywords: A Vocabulary of Culture and Society (London: Fontana, 1976), 174–5. 7. G. Beard, American Nervousness: Its Causes and Consequences (New York, 1881), vi. See also M. Gijswijt-Hofstra and Roy Porter (eds), Cultures of Neurasthenia from Beard to the First World War (Amsterdam: Rodopi, 2001). 8. Oxford English Dictionary, quoted in Daniel Pick, Faces of Degeneration: A European Disorder, c.1848–1918 (Cambridge: Cambridge University Press, 1989), 216. 9. Ibid. 61.

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10. Galina Kichigina, The Imperial Laboratory: Experimental Physiology and Clinical Medicine in Post-Crimean Russia (Amsterdam: Rodopi, 2009), 158. 11. Max Weber, ‘Bureaucracy’, in H. H. Gerth and C. Wright Mills (trans and eds), From Max Weber: Essays in Sociology (London: Routledge, 1948), 196–244. 12. Steve Sturdy and Roger Cooter, ‘Science, Scientific Management, and the Transformation of Medicine in Britain, c.1870–1950’, History of Science 36 (1998), 421–66. 13. On the origins of the term, see ibid, 453–54, n.26. 14. Charles Macalister, The Origin and History of the Liverpool Royal Southern Hospital with Personal Reminiscences (Liverpool, 1936), 61–2. 15. William Mayo, ‘Present-Day Surgery in England and Scotland: From Notes Made on a Recent Short Visit’, reprinted from Journal of the Minnesota State Medical Association (1 December 1907), 6. 16. Weber, ‘Bureaucracy’, 205. 17. Daniel Pick, War Machine: The Rationalization of Slaughter in the Modern Age (New Haven, CT: Yale University Press, 1993). 18. Max Weber, ‘The Meaning of Discipline’, in Gerth and Mills (eds), From Max Weber, 261. 19. Cited in Pick, War Machine, 101. 20. Pick, War Machine, 165–88. 21. Robert Weldon, Bitter Wounds: German Victims of the Great War, 1914–1939 (Ithaca: Cornell University Press, 1984), 61. 22. Mark Harrison, Medicine and Victory: British Military Medicine in the Second World War (Oxford: Oxford University Press, 2004). 23. Gerald Kutcher, Contested Medicine: Cancer Research and the Military (Chicago: University of Chicago Press, 2009). 24. Ulrich Beck, ‘How Modern is Modern Society?’, Theory, Culture and Society 9:2 (1992), 163–9, at 163. 25. Sandra Harding, Sciences from Below: Feminisms, Postcolonialities, and Modernities (Durham, NC: Duke University Press, 2008). 26. Modris Eksteins, Rites of Spring: The Great War and the Birth of the Modern Age (New York: Doubleday, 1989), xvi. 27. Samuel Hynes, A War Imagined: The First World War and English Culture (New York: Atheneum, 1991). 28. Paul Fussell, The Great War and Modern Memory (Oxford: Oxford University Press, 1975). Pick, War Machine, and Jay Winter, Sites of Memory, Sites of Mourning: The Great War in European Cultural History (Cambridge: Cambridge University Press, 1996), both contest the decisiveness of the war in the making of the modern. 29. Thomas Schlich, ‘The Perfect Machine: Lorenz Böhler’s Rationalized Fracture Treatment in World War One’, Isis 100 (December, 2009), 758–91. On English modernism, see Stella Tillyard, The Impact of Modernism, 1900–1920 (London: Routledge, 1988). 30. Nikolas Rose, The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the TwentyFirst Century (Princeton: Princeton University Press, 2007), 26. 31. Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan (New York: Vintage, 1979), 25. 32. Erin O’Connor, Raw Material: Producing Pathology in Victorian Culture (Durham, NC: Duke University Press, 2000), 215. 33. Michel Foucault, ‘Questions of Methods’, in G. Burchell, C. Gordon, and P. Miller (eds), The Foucault Effect: Studies in Governmentality, (Chicago: Chicago University Press, 1991), 79.

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34. Lisa Long, Rehabilitating Bodies: Health, History, and the American Civil War (Philadelphia: University of Pennsylvania Press, 2004). 35. Jose Harris, Private Lives, Public Spirit: Britain 1870–1914 (New York: Penguin, 1994), cited in Martin Daunton and Bernhard Rieger (eds), Meanings of Modernity: Britain from the late-Victorian Era to World War II (Oxford: Berg, 2001), 5. 36. Joan W. Scott, ‘The Evidence of Experience’, Critical Inquiry 17 (Summer 1991), 773–97. 37. Robert Musil, The Man without Qualities, trans. Sophie Wilkins and Burton Pike (London: Picador, 1997), 231. 38. Martin Kemp, Seen/Unseen: Art, Science, and Intuition from Leonardo to the Hubble Telescope (Oxford: Oxford University Press, 2006), 2. 39. Steve Fuller, review of Smail in Interdisciplinary Science Reviews, 34 (2009), 389. On the scientificity of contemporary ‘neuro-talk’ and its dangers, see Matthew B. Crawford, ‘The Limits of Neuro-Talk’, The New Atlantis (Winter 2008), 65–78. 40. Daniel Dennett, Darwin’s Dangerous Idea: Evolution and the Meanings of Life (London, 1995), 477; Nikolas Rose and Carlos Novas, ‘Biological Citizenship’, in Aihwa Ong and Stephen J. Collier (eds), Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems (Oxford: Blackwell, 2005), 439–63. 41. Fernando Vidal, ‘Brainhood, Anthropological Figure of Modernity’, History of the Human Sciences 22 (2009), 5–36; Fay Bound Alberti, Matters of the Heart: History, Medicine, and Emotion (Oxford: Oxford University Press, 2010). 42. Arjun Appadurai, Modernity at Large: Cultural Dimensions of Globalization (Minneapolis: University of Minnesota Press, 1996), 1.

Select Bibliography Bayly, C. A., The Birth of the Modern World (Oxford: Blackwell, 2004). Cooter, Roger, Surgery and Society in Peace and War: Orthopaedics and the Organization of Modern Medicine, 1880–1948 (London: Macmillan, 1993). —— , ‘The Turn of the Body: History and the Politics of the Corporeal’, ARBOR Ciencia, Pensamiento y cultura (forthcoming). Foucault, Michel, ‘The Birth of Bio-Power’, in Paul Rabinow and Nikolas Rose (eds), The Essential Foucault (New York: The New Press, 2003), 202–7. Jameson, Frederic, Postmodernism or the Cultural Logic of Late Capitalism (London: Verso, 1991). Lerner, Paul, and Mark S. Micale (eds), Traumatic Pasts: Studies in History, Psychiatry and Trauma in the Modern Age (Cambridge: Cambridge University Press, 2001). Rose, Nikolas, and Paul Rabinow, ‘Biopower Today’, Biosocieties, 1 (2006), 195–218. Searle, G. R., The Quest for National Efficiency, 2nd edn (London: Ashfield Press, 1990). Shildrick, Margrit, Leaky Bodies and Boundaries: Feminism, Postmodernism and (Bio)ethics (London: Routledge, 1997). Thomson, Mathew, ‘Psychology and the Consciousness of Modernity in Early Twentieth Century Britain’, in Martin Daunton and Bernhard Rieger (eds), Meanings of Modernity: Britain from the late-Victorian Era to World War II (Oxford: Berg, 2001), 97–115.

chapter 7

con tem por a ry history of m edici n e a n d hea lth v irginia berridge

When Professor Robert Seton Watson, Masaryk Professor of Central European History in the School of Slavonic and East European Studies, delivered London University’s Creighton lecture in 1928, his subject was contemporary history. He avoided too exact a definition. ‘It may perhaps suffice to call it the history of the period upon which men still at the height of their powers can look back.’1 In 1928, it was debatable whether this would be 1871, 1878, or 1890. The definition of the area would change with the passage of time. Unlike Tudor and Stuart history, where the time frame could not be changed, what counted as contemporary history would inevitably alter as time itself passed. Defining a time frame now faces the same issues. A few years ago contemporary history would have meant the history of the Second World War and just after. Historians would tiptoe gingerly into the late 1940s and early 1950s. But already that time barrier has changed. My own work, undertaken in the early 1990s, on the history of HIV/AIDS policies in the 1980s and 1990s was highly unusual as an historical exercise because it framed an historical analysis round events that had only just happened, or that had yet to happen when the research began.2 Work on the 1970s and 1980s is more common now. The contemporary history of health and medicine has expanded into new areas and time frames, with cross-national variations in emphasis that tell us something about different national histories. There may, as Rodney Lowe put it, be ‘a lingering suspicion of historians as a profession that “contemporary history” is little more than a tautology’, but that attitude is less common than it was.3 This chapter argues that the contemporary history of health and medicine presents some particular challenges, however, for the nature of historians’ involvement in the object of their study and for their relationships with other disciplines and with the field of policy. Too great an involvement in contemporary debates, rather than analysis of them, brings with it the danger of a neo-Whig history of medicine.

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The establishment of contemporary history In Britain, the emergence of contemporary history as an academic sub-area began in the 1980s. The historical debate that energized the area centred on the rationale for the emergence of the post-war welfare state, and whether there had been political consensus. The Institute of Contemporary British History was established by Peter Hennessy and Anthony Seldon in 1986 and contemporary history had a ‘high politics’ and also an economic, Treasury history focus at the start. Similar centres for contemporary history were set up in other parts of Europe and, following the fall of communism, some of the previous ‘Iron Curtain’ countries, the Czech Republic, Slovenia, and Romania, also set up institutions of contemporary history in order to understand their recent histories. In other countries, the mainspring was methodological: oral history and women’s history provided the impetus in France, Sweden, and the Netherlands.4 In the USA the impetus in part came from the creation of the Presidential libraries and archives for health and medicine, and posts of official historian were created in the National Institutes of Health. Health and medicine did not automatically form part of the developments in contemporary history. A handbook on contemporary history, published in 1996, had only one brief mention of health, in a discussion of electronic record-keeping.5 By 2007, a companion to contemporary Britain had a chapter on health as a matter of course.6 Two developments had a significant influence. One came from the British government’s official history programme. Located in the Cabinet Office, the official histories are intended not only to sustain a collective memory for the policy-maker but also to ‘give truth a quick start’, to enable historians to construct their own informed and independent accounts of the recent past. The publication in 1988 and in 1996 of Charles Webster’s two-volume official history of the National Health Service, taking the story up to 1979, a product of monumental scholarship and strong political commitment, was the first time health had figured directly in the programme. Webster had already contributed to the debate on ‘consensus’ and published a further political history of the NHS in time for the fiftieth anniversary of the service in 1998.7 The other factor was the advent of HIV/AIDS during the 1980s. A disease where ‘no one knew anything’, AIDS stimulated a revival of interest in history and current events in the UK and the USA. Given that there was no template for action in the present, could history provide models for action? In the United States in 1988, Elizabeth Fee and Daniel Fox published AIDS: The Burdens of History, a collection of essays that drew analogies between past and present. What could past epidemics tell us about how to respond to AIDS? Debates about quarantine in the past or the ‘enforcement of health’ seemed appropriate. By the time the editors published a second volume in 1992, the focus was different. ‘The history of AIDS’, they declared, ‘is a problem in contemporary history.’ The book’s content reflected this change: there were essays on the recent history of HIV/

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AIDS, not on past historical analogies.8 AIDS itself was history. However, the syndrome could not be understood without context and hence stimulated interest in the ‘prehistory’ of the areas with which it intersected.9 This inevitably meant a focus on post-war history as well as more distant historical developments.

Recent trends in the contemporary history of health and medicine There is now a crop of overview histories that encompass the nineteenth and twentieth centuries, taking the story into the near present. Those that focus exclusively on the post-war years mostly deal with welfare, and only one focuses on health.10 The publication of Roger Cooter and John Pickstone’s edited collection Medicine in the Twentieth Century in 2000 was significant.11 The book was an attempt to break out of the traditional central state, health service focus and the book was organized round the themes of ‘power’, ‘bodies’, and ‘ experiences’, aiming to show how medicine had become central to the state, the industrial economy, and the welfare of individuals. Chapters dealt with pre- and post-1945 events, but the authors still lamented the paucity of historical studies on which to build. This book’s value also lay in its cross-national compass with a mix of European, British, and American perspectives. How has the field developed since then? A content analysis of contemporary history articles, defined here as those dealing with the post-1945 period, published in three major medical history journals since 2000 (the British journals Social History of Medicine (SHM) and Medical History and the American Bulletin of the History of Medicine), revealed a growth in post-1945 studies, a trend more strongly represented in the British journals than in the American. In Britain, the impetus for contemporary history had come from social history. In the early twenty-first century Medical History has published post-1945 history less frequently than SHM. However, since 2006, contemporary history has expanded in all the journals, with a greater European focus in Medical History and a cancer special issue in the Bulletin, which contained much post-1945 content from both British and American contributors. Articles in these journals and the books they chose to review showed that some themes and areas were common among researchers into contemporary health history. The rise of post-war biomedicine, sexuality and sexual health, illicit drugs, the pharmaceutical industry, and clinical trials were subjects that had animated researchers in Britain, the USA, and Europe. However, the ways in which these subjects had been approached differed, with divergences among American, British, and European approaches. The American work, broadly characterized, focused more on individuals or diseases, while some of the British work was more interested in policy at both local and national levels. For contemporary history, the traditional British/American nexus of medical history was less strong and there were signs of a greater community of interest between British and European researchers.

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The ‘AIDS effect’ on research and publication continued. In Britain and Europe studies of sexuality, sexual health, and sexual health policy took forward the interest in the ‘pre-history’ of AIDS. At the European Social Science History conferences, important for linking historians of health with allied research areas, it was noticeable how packed the sessions on sexuality and sexual politics were, much work dealing with contemporary history. A consistent body of work developed on sexual health in particular countries, for example Scotland with its distinctive, more punitive, public health tradition, and also the Netherlands.12 The history of sexuality and family planning and an interest in the history of the pill was common to both British and American historians, perhaps deriving more from the earlier impetus provided by women’s history than from a specific ‘AIDS effect’.13 In the USA the direct history of AIDS itself (which attracted less recent attention in the UK) continued as an interest. Peter Baldwin’s analysis of responses to AIDS was the first attempt to develop a cross-national analysis since the volumes of policy case studies published in the late 1980s and early 1990s. His argument that the public health traditions of particular countries had determined their responses to HIV did not win universal support. Published collections of oral histories of HIV/AIDS in the USA and UK provided the raw material for contemporary history.14 American interest in the history of sexuality also had a different focus. Work on the controversial history of the Tuskegee syphilis study showed the combination of interest in race, research ethics, and sexuality that marked a different outlook in US contemporary history. AIDS history outside the USA was energized. A study of AIDS in South Africa and the role of Tabo Mbeki was an historical attempt to understand the South African response, while a more general overview of African AIDS history appeared. AIDS policies in Sweden and Denmark were examined through the political science concept of ‘path dependency’.15 The history of illicit drugs also became more lively and diverse. A few years ago, I lamented the lack of research-based new work and the recycling of familiar material and tired policy clichés. Much new research dealing with the post-war period subsequently appeared on: drug policy and research in both the UK and America; treatment policy in the Netherlands; LSD therapy; the international dimensions of drug policy and control; and oral histories.16 New networks formed. A professional society and its journal, which previously focused on US temperance history, widened to include drugs and published contemporary history. There were important studies of Foetal Alcohol Syndrome, an historical interest that symbolized the importance of that construct in the USA, but US alcohol policy was less well researched than the UK version.17 Smoking was another form of ‘substance use’. Allan Brandt’s The Cigarette Century focused partly on the post-war period, providing an analysis of industry documents and stressing the obfuscation of the US tobacco industry. Berridge’s Marketing Health dealt only with the post-war years in the UK and took a different view, setting the smoking issue within the context of specifically British developments and seeing smoking as emblematic of the rise of a new style of public health after 1945. Rosemary Elliot’s study of women and smoking used oral history to stress the importance of gender.18

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Smoking and drugs intersect with two other areas of contemporary history: public health and mental health. Public health as a concept and practice can have many meanings. One is the organization of services. No full-scale policy study has been published since Jane Lewis’s research, twenty years ago, which examined the ideology of public health and the change that took place in the location of UK public health in the early 1970s. However, biographies of local Medical Officers of Health contributed to the debate about the virtues of the former local government-based system and there were useful studies of services in Leicester and Manchester.19 Specific diseases such as tuberculosis and polio attracted attention, in part because they had revived as public health issues in the late twentieth century.20 In the post-war years the change in public health ideology and a new focus on ‘lifestyle’ were researched through studies of the rise of public health science, epidemiology in particular. That was part of the ‘AIDS effect’, the power of epidemiology in defining a new syndrome.21 Diet, obesity, and heart disease, parallel issues to those raised by smoking, began to attract research interest. One of the most innovative approaches was Offer’s study of changing body size, which argued that both psychological and economic imperatives were involved in the post-war rise in body weight.22 The history of national and international public health policy-making remained under-exploited: research on the history of the UK Chief Medical Officer and a witness seminar on public health in the 1980s and 1990s gave an indication of further research possibilities.23 Research on mental health history also developed. History of medicine has long had a strong interest in the history of insanity, and this also marked research into the post-war years. Gittins’s study of the mental hospital as a ‘total institution’ built on her own personal connections and empathy for the lost world of the mental institution.24 Psychotherapy and psychology, and the rise of the post-war ‘drug revolution’ in psychiatry, were explored.25 User movements, a feature of the post-war period, initially attracted the attention of sociologist histories, but work from historians also appeared.26 Post-war developments in mental health seemed to exemplify the optimism of that period about the power of science and the new technologies of drug treatment. Much contemporary history emanated from history of science: science studies and the sociology of scientific knowledge impacted on the contemporary history of health and medicine. For mental health, the advent of drug treatments was greeted in a positive way: only subsequently were responses less enthusiastic. Oral histories and historically based critiques of the rise of the anti-depressants and psychopharmacology were produced by participants in current debates.27 The rise of drug treatments and of the pharmaceutical industry as a player in clinical medicine and in policy was addressed, alongside the post-war rise of the clinical trial and the science/industry nexus.28 The stories of thalidomide and the pill provided defining moments in the post-war history of drugs and their regulation.29 Medical technology offered new possibilities and also brought the issue of rationing onto the agenda.30 Areas such as molecular biology and the ‘new genetics’ seemed to offer fresh scientific possibilities.31 Contemporary history was not a British and American enclave. European researchers were increasingly involved, with studies from Norway and the Netherlands, and also

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from further afield, from New Zealand and South Africa.32 In France too, historians of science and medicine were active in researching the post-war history of science and its intersections with public health.33 Cross-national comparative studies were limited in number but provided valuable insights: Marks’s study of the differential responses to pill safety in the UK and USA; Bryder’s study of the differential adoption of Bacillus Calmette-Guérin (BCG) vaccination for TB; and Lindner and Blume’s study of vaccination policies in European countries. They showed that public health authorities in Britain, Germany, and the Netherlands responded differently to the emergence of both the Salk polio vaccine (IPV) in the mid-1950s and the Sabin polio vaccine (OPV) a few years later. Lindner and Blume concluded that in addition to differences in the structural features of health systems and in the relations between vaccine production and public health systems, national attitudes to vaccination and to the vaccine also played a part.34 Discrete areas such as occupational health and environmental history, explored further by Christopher Sellers in Chapter 25, have also contributed to contemporary history. A current growth area is the history of international health, the post-war rise of the World Health Organization (WHO) and its role in malaria, in vaccination campaigns, and in the diffusion of ideas about primary health care. This is an area where a critical mass of research is developing, through both WHO’s own efforts and those of other researchers.35 The coming of globalization as a ‘new development’ at the international level offers opportunities for historians to deconstruct vocabulary and practice. It is surprising that some areas of contemporary history have not developed in a way that might have been expected. The history of health services is one. There does not seem to have been an ‘NHS effect’ akin to the ‘AIDS effect’ on contemporary history. The sixtieth anniversary of the NHS in 2008 provided a stimulus for the publication of more health service history; however, Martin Gorsky’s overview of the historiography commented on how few analyses emanated from within the discipline.36 In the USA, debates on health care reform stimulated more discussion. Aspects of post-war service history in Britain were nevertheless researched. The history of general practice and issues of health services costs, for example, attracted attention.37 The rise of evidence-based medicine and the relationship between evidence, policy, and practice that marked the 1980s received an initial examination.38 Mohan’s work on hospital planning, development, and governance also usefully included a study of hospital development in the Newcastle region, including the implementation of the Hospital Plan.39 Central policy-making attracted less attention: a witness seminar and other material on inequalities, the Black Report of 1980, and one on the Griffiths management reforms provided data for further analysis.40 It seemed that health service historians were reluctant to move out of the interwar years, the period on which their work concentrated. Many of the concerns of contemporary historians of health and medicine were common across national boundaries but the ways in which they approached them differed. In the USA, with the exception of drug policy, there were few studies of policy-making and the engines of government, perhaps because of the differing nature of the American state. Cantor’s volume and special issue on cancer in the twentieth century (with some

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post-war work) exemplified the differences. The UK studies were more firmly rooted in institutions and in policy, with studies of the Medical Research Council, the role of the Royal College of Physicians in relation to government, and the role of local organizations in education and screening, while the US work focused more on individual experience and history.41

Who does contemporary history and how? Contemporary history is not the exclusive preserve of the professional historian. Some leading historians in the UK field, Peter Hennessy, for example, began as journalists. Allied disciplines such as political science provide valuable theoretical insights or concepts such as ‘path dependency’ and ‘policy communities’ or ‘networks’. These can enrich the historian’s interpretation of events. The role of participants and ‘actors’, strong in other areas of history and within medical history more generally, is also common in contemporary history. Retired doctors and scientists have always written medical history. Being part of the field has sometimes served to give their accounts a higher profile in the contemporary health arena.42 But their role within contemporary history can be problematic, as discussed below. The historical approach, while allied in some ways to these other disciplines and to participants in the field, is also different from them. One commentator called it ‘slow journalism’. But it is more than that: it offers distance, an appreciation of change and continuity over time, a contextualization based on the assessment of competing sources and accounts. In some respects studying contemporary history is no different from researching any other period of history. As always, it is a matter of assessing different forms and styles of evidence, of triangulation as social scientists would call it, and the production of an analysis that can bear scrutiny by colleagues and others. But there are specific methodological challenges in contemporary history. Archives are not always available in the organized way that is more likely for other periods. In the 1990s, when I was working on HIV/AIDS policy-making, I referred to ‘archives on the run’. Typically most official government archives for the recent period would be closed, so archives were obtained wherever possible. For a time, I spent every Thursday afternoon in the office of a leading AIDS doctor while he did his ward round. He allowed me to work there on the papers of a key committee of which he had been a member. These were not available at that time to a researcher in The National Archives (TNA), where application needed to be made to see papers that came under the ‘thirty-year rule’ (the UK archival regulation of access to official documentation). This, if granted, would entail a trip to the Department of Health’s archival store in Nelson, Lancashire. Now matters are different. The Freedom of Information Act has opened up access to recent papers, and the process of making a Freedom of Information request has become institutionalized in TNA application processes. However, this does not guarantee access, and record-keeping practices vary between departments. For a recent study of

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the role of the drug voluntary sector and of drug user groups, the Home Office was unable to find the papers of its Voluntary Sector Unit that had funded voluntary organization in the 1970s. Once again, uncatalogued ‘archives on the run’, on loan from a retired psychiatrist, proved useful. Organizational changes have often meant that records are lost between departments and their significance is unappreciated. A particular example is the many changes that have overtaken the central UK governments health education function, which has led to uncertainty over the main records of the organization and to the potential loss of valuable ‘grey material’ that the organization has produced.43 The proposed changes in UK records policy that will make archives available after fifteen years instead of thirty will have further implications for contemporary history. This tendency towards greater openness has also been stimulated by the accessibility of online archives. In the UK, TNA is digitizing material, often with relevance to its major clientele of family historians. However, Cabinet minutes are now online and there is a culture of greater openness in government departments. The papers of a key enquiry may be placed on a website, as they were for the BSE enquiry or that into the activities of Harold Shipman, the GP who killed many of his elderly patients. But websites can change overnight. One PhD student found that her material on UK Biobank disappeared without warning when the website was changed. TNA are archiving examples of websites to deal with this problem. Not all such archives are official ones. A significant development has been the online availability of tobacco industry archives taken from tobacco companies as part of a legal settlement in the USA. These exercises have also potentially changed the ways in which contemporary historians ‘do history’ and configured the user of the document in a way that has made research different from the contextualized study of paper archives. There have also been overview exercises, seeking to encourage access to and awareness of the archival material for recent history. The study of AIDS archives was an early example of this approach and a similar web-based approach for the archives of voluntary organizations or non-governmental organizations has been maintained at the University of Birmingham.44 However, greater openness has not been universal in the study of contemporary history. Data protection issues have caused access to be denied if personal material about people who might still be alive is within deposited archives. This can be the case even if the researcher is not interested in individual patients. Oral history has continued to be a key resource for contemporary history. The major focus in this field since the 1970s was ‘history from below’, that is the use of the method to recover the life experiences of those ‘hidden from history’. ‘History from below’ was a significant area of contemporary history. But the history of elites was also important and was less studied through oral methods. Elite oral histories tended to focus only on the role of scientific and medical professionals. The history of health policy itself and the engines and networks of power could also be profitably examined through this method. Rudolf Klein’s work was based on the study of health policy as an inside/outside observer, with contacts in health policy utilized as background information.45 Some contemporary historians have begun to use oral history more overtly as a methodology. Nevertheless, little oral history work on NHS policy-making was drawn on during the

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sixtieth anniversary celebrations. And there have been many other aspects of health policy-making outside service development that could be studied in this way. The methodology of elite oral history in contemporary health history has been analysed; it has implications for relationships between the researcher and those being researched.46 The setting and format, for example, can make a difference. Sometimes one gets more from an interview, sometimes a witness seminar can be an excellent format. At a witness seminar on the Black Report, the well-known story of how the Conservative government had blocked the report and failed to publish it was reviewed. However, other dimensions started to emerge through the interactions that took place. The sociologist Peter Townsend talked about how he and the public health researcher Jerry Morris could not agree about the implications of the data and so the report was delayed; it was presented, not to the outgoing Labour government, but to the incoming Conservatives. In the seminar, the two civil servants present who had had responsibility for the enquiry into inequalities showed their irritation with the researchers, leading to an exchange between former chief scientist Sir Arthur Buller and Sir Douglas Black. That sort of exchange, which added a new dimension to the story, would never have been achieved through the individual interview format.47 Ethical review also plays more of a role for the contemporary history of health, in particular if one works in a medical institution. NHS patient records must be accessed through local ethics committees and the parent institution will also have its ethics committee to which application must be made where interviewing is concerned. In a medical institution the purpose of individual interviewing as a method, rather than survey research or the randomized controlled trial, may not always be understood, and this can create problems in obtaining approval. The style of historical research that is essentially exploratory and not hypothesis driven can also be inimical to ethics committees more used to the science or public health model.

The position of the contemporary historian In writing contemporary history, the historian is at the mercy of what Eric Hobsbawm called ‘short term movements of the historical weather’. Daniel Fox termed it ‘combat history’: the positioning of the historian would change as events themselves unfolded. This is an issue that has made historians wary about contemporary history. Are historians too near to contemporary events to write a detached and informed analysis? In some senses this is the case for every form of history, which is all time- and persondependent. However, this concern has particularly affected areas of the contemporary history of health and medicine in recent years. In writing such recent history, the contemporary historian is often treading on controversial ground. The history raises issues of historical positioning in a more direct way than more distant history. Should the

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contemporary historian use history to ‘take sides’? The American drug historian David Courtwright recently distinguished between what he called ‘policy cools’ and ‘policy hots’. The latter type of historian used their history as a battering ram, an activist tool, in contemporary events, while the former was more distant and detached. Working on issues that are still ‘live’ as policy seems to make a difference to the sort of history produced.48 This issue has been divisive amongst American historians of medicine and has contributed to the differences with British and European contemporary history alluded to in this chapter. Activism is an urgent issue for US historians. The use of legal process to decide policy issues in the American system has had much to do with this. Historians have testified on one side or the other in legal cases involving industrial interests, for and against the tobacco industry and also in connection with occupational health issues. American historians have taken pride in using history as an activist tool. Rosner and Markowitz have discussed their involvement with occupational litigation and Brandt appeared for anti-tobacco-industry interests as an expert witness. American historians have argued that the legal process and the need to argue a particular case do not detract from historical method. Rothman has argued that contemporary historians can serve both Clio and client, but then concludes: ‘To enter the courtroom is to do many things, but it is not to do history. The essential attributes that we treasure most about historical inquiry have to be left outside the door. The scope of analysis is narrowed, the imagination is constrained, and the curiosity curtailed.’49 The use of legal process to achieve health ends is unusual in the British context and in general history does not enter the law courts, with the exception of Richard Evans’s involvement in the David Irving case, which involved discussion of interpretation of the Second World War. A directly committed activist stance is less usual on the part of British and European historians of the recent past. Thus there may be different objectives for historical work and for research on similar primary source material by other health researchers. My own recent work on smoking is a case in point. My interviews were with public health officials and others with interests in smoking, whom I saw as representing changes in the post-war ideology of public health, and my archival research encompassed a wide range of government, industry, and pressure group sources. My public health colleagues, on the other hand, were committed to an activist, anti-industry stance and thus their research was on industry archives alone, with a predetermined focus on the bad things the industry has done. There are tensions between the aims of history and current policy interests. Historical studies and interpretations have been criticized by ‘policy actors’ who do not understand historians’ mode of argument and see matters only in terms of ‘taking sides’. Falling into line with this ‘heroes and villains’ approach to recent history has dangers for contemporary history. It opens up the possibility of a neo-Whig approach to medical history. It can also assume a type of ‘global history’, dominated by what has happened in the USA. It raises the issues of partisanship and the lack of critical distance discussed several decades ago as part of the then new social history of medicine. The assumption made is that the present framing of issues is ‘right’ in a way that social historians used to

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critique. Then, this stance was seen as looking at history through the ‘wrong end of the telescope’ and historians sought to understand the past on its own terms. This stance should also be applied to contemporary history: there cannot be an automatic pay-off for the present from the recent past. We cannot and should not become smoking activists or drug liberalization advocates just because we are interviewing and analysing those policy actors. Although not all commentators would agree, historians must maintain distance; otherwise, all we will write is ‘advocacy history’. Nevertheless, historians do not have to be divorced from current policy, and in fact those working on contemporary history would find it difficult to be so. It is rather a matter of opening up options for discussion or new thinking rather than of closing down discussion by seeing past developments as ‘right’ or ‘wrong’. In recent years, there have been growing demands for historians to improve their connections with policy-makers and, increasingly from UK funders, to demonstrate the ‘impact’ of their work on policy. In Britain, a website and partnership called History and Policy has been set up to bring the perspectives of history more closely into policy-making.50 Impact and the role of history is a more complex issue than it might look at first sight. Abigail Woods, whose research on the history of slaughter and vaccination as alternative policy options for foot-and-mouth disease was reframed by the media during the 2001 outbreak, found this through personal experience.51 How evidence (including history) relates to policy and policy-makers can be informed by the extensive discussion of the research–policy relationship that has taken place in health circles in recent years. There, the idea of a rational relationship has been discounted and theories such as the ‘enlightenment effect’ of research have been given currency. A research-based examination of how history did in practice impact on policy, and in what circumstances, highlighted a number of salient issues.52 Access to networks in policy was important, often through social scientists, who acted as ‘surrogate historians’. The timing and location of publication affected impact and there was a need to present history as an interpretative rather than a fact-driven approach. One policy interviewee commented that historians should be brought in precisely because they were not the ‘usual suspects’: ‘they don’t tell us what to do.’ This was quite the opposite view to the American style of activist ‘expert witness’ history. In the British context, there is more mileage in this style of influence than in the American approach, given that the nature of the state and the engines of power in the UK are so different to those across the Atlantic.

Conclusion: where next for contemporary history? There is much contemporary history research to be done. Contemporary historians of health and medicine have done little to exploit the possibilities of visual sources and of film and television after the Second World War.53 The greater availability of media online

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through gateways and further training should accustom historians to their use. The contemporary history of health and medicine for countries outside Europe and North America will undergo development with more work on tropical countries. The cultural history of medicine and of popular attitudes to health and science post-war is relatively sparse. In the USA, Nancy Tomes’s work on health consumerism invites the possibility of exploring the cultural context of modern medicine.54 An interest in space and collaborative work with cultural geography is already emerging in new research. There is more that could be done in terms of oral history both ‘from below’ and ‘from above’ and the methodology could be better integrated into mainstream contemporary history. The history of health policy and services is in need of development. Local and regional studies, as well as national ones, and investigation of voluntarism and health pressure groups could all be on the agenda. The role and influence of those organizations cross-nationally and at the international level is a next step. Race and ethnicity have figured in American contemporary history but have attracted little interest elsewhere. Contemporary history has been primarily qualitative, but there is much that could be done through the reuse and analysis of existing survey material. Work by epidemiologists and other health researchers on the Aberdeen Child Development Survey of the 1950s, for example, points the way towards potential future collaborations between epidemiologists and historians. Health history needs to further establish itself as an entity in its own right, not just as an adjunct of welfare. There is certainly no lack of vitality in the field and the passing of time itself will bring fresh areas and time frames into view. In terms of the ‘use of history’, this field of medical and health history is best positioned to have impact with policy-makers. The use of history is still not automatic and needs to be argued for. Historians who wish their work to have impact will need to proceed with caution, to be aware of the boundaries that surround those relationships. They should avoid ‘going native’ in a way that will simply pander to present-day preconceptions rather than illuminating them.

Notes 1. R. Seton Watson, ‘A Plea for the Study of Contemporary History’, in D. Bates, J. Wallis, and J. Winters (eds), The Creighton Century, 1907–2007 (London: Institute of Historical Research, 2009), 57–79. 2. V. Berridge, AIDS in the U.K.: The Making of Policy 1981–1994 (Oxford: Oxford University Press, 1996). 3. R. Lowe, ‘Official History’ webpage, available at http://www.history.ac.uk/makinghistory/ resources/articles/official_history.html, accessed 30 July 2009. 4. M. Kandiah, ‘Contemporary History’ webpage, available at http://www.history.ac.uk/ makinghistory/resources/articles/contemporary_history.html, accessed 30 July 2009. 5. E. Higgs, ‘Electronic Record Keeping in the UK Government and the NHS: Opportunity, Challenge or Threat?’, in B. Brivati, J. Buxton, and A. Seldon (eds), The Contemporary History Handbook (Manchester: Manchester University Press, 1996), 451–61.

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6. J. Welshman, ‘Health’, in P. Addison and H. Jones (eds), A Companion to Contemporary Britain, 1939–2000 (Oxford: Blackwell, 2007), 296–314. 7. C. Webster, The Health Services Since the War, 2 vols (London: Stationery Office, 1988–96); idem, The NHS: A Political History (Oxford: Oxford University Press, 1998); idem, ‘Conflict and Consensus: Explaining the British Health Service’, Twentieth Century British History 1 (1990), 115–51. 8. E. Fee and D. M. Fox (eds), AIDS: The Burdens of History (Berkeley: University of California Press, 1988); eidem (eds), AIDS: The Making of a Chronic Disease (Berkeley: University of California Press, 1992). 9. V. Berridge and P. Strong (eds), AIDS and Contemporary History (Cambridge: Cambridge University Press, 1993). 10. R. Lowe, The Welfare State in Britain since 1945 (Basingstoke: Palgrave Macmillan, 2005); N. Timmins, The Five Giants: A Biography of the Welfare State (London: Fontana, 1996); V. Berridge, Health and Society in Britain since 1939 (Cambridge: Cambridge University Press, 1999). 11. R. Cooter and J. Pickstone, Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000). 12. R. Davidson, Dangerous Liaisons: A Social History of Venereal Disease in Twentieth Century Scotland (Amsterdam: Rodopi, 2000); A. Mooij, Out of otherness: characters and narrators in the Dutch Venereal Disease Debates, 1850–1990 (Amsterdam: Rodopi, 1998). 13. Hera Cook, The Long Sexual Revolution: English Women, Sex and Contraception, 1800–1975 (Oxford: Oxford University Press, 2004); Lara Marks, Sexual Chemistry: A History of the Contraceptive Pill (New Haven, CT: Yale University Press, 2001). 14. P. Baldwin, Disease and Democracy: The Industrialised World Faces AIDS (Berkeley: University of California Press, 2005); R. Bayer and G. Oppenheimer, AIDS Doctors: Voices from the Epidemic (Oxford: Oxford University Press, 2000). 15. J. Iliffe, The African AIDS Epidemic: A History (Oxford: James Currey, 2006); K.van Rijn, ‘The Politics of Uncertainty: The AIDS debate, Thabo Mbeki and the South African Government Response’, Social History of Medicine, 19 (2006), 521–38; S. Vallgarda, ‘Problematizations and path dependency: HIV/AIDS policies in Denmark and Sweden’, Medical History 51 (2007), 99–112. 16. A. Mold, Heroin: The Treatment of Addiction in Twentieth Century Britain (DeKalb: Northern Illinois University Press, 2008); N. Campbell, Discovering Addiction: The Science and Politics of Substance Abuse Research (Ann Arbor: University of Michigan Press, 2007); E. Dyck, Psychedelic Psychiatry: LSD from Clinic to Campus (Baltimore: Johns Hopkins University Press, 2008); G. Edwards, Addiction: Evolution of a Specialist Field (Oxford: Blackwell, 2002). 17. B. Thom, Dealing with Drink: Alcohol and Social Policy: From Treatment to Management (London: Free Association Books, 1999); J. Greenaway, Drink and British Politics since 1830: A Study in Policy Making (Basingstoke: Palgrave Macmillan, 2002); E. M. Armstrong, Conceiving Risk, Bearing Responsibility: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder (Baltimore/London: Johns Hopkins University Press, 2003). 18. A. Brandt, The Cigarette Century: The Rise, Fall and Deadly Persistence of the Product That Defined America (New York: Basic Books, 2007); V. Berridge, Marketing Health: Smoking and the Discourse of Public Health in Britain, 1945–2000 (Oxford: Oxford University Press, 2007); R. Elliot, Women and Smoking since 1890 (London: Routledge, 2008).

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19. J. Welshman, Municipal Medicine: Public Health in Twentieth Century Britain (Oxford: Peter Lang, 2000); E. L. Jones and J. V. Pickstone, The Quest for Public Health in Manchester: The Industrial City, the NHS and the Recent History (Manchester: NHS Primary Care Trust, 2008). 20. R. Coker, ‘Civil Liberties and Public Good: Detention of Tuberculous Patients and the Public Health Act 1984’, Medical History 45 (2001), 341–58; J. Welshman, ‘Tuberculosis and Ethnicity in England and Wales, 1950–70’, Sociology of Health and Illness 22 (2000), 858– 82; A. Bashford, Medicine at the Border: Disease, Globalization and Security, 1850 to the Present (Basingstoke: Palgrave Macmillan, 2006); T. Gould, A Summer Plague: Polio and Its Survivors (New Haven, CT/London: Yale University Press, 1995). 21. L. Berlivet, ‘ “Association or Causation?”: The Debate on the Scientific Status of Risk Factor Epidemiology, 1947–c.1965’, in V. Berridge (ed.), Making Health Policy: Networks in Research and Policy after 1945 (Amsterdam: Rodopi, 2005), 39–74; W. G. Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution (Rochester, NY: University of Rochester Press, 2003). 22. A. Offer, ‘Body Weight and Self-control in the US and Britain since the 1950s’, Social History of Medicine 14 (2001), 79–106. 23. S. Sheard and L. Donaldson, The Nation’s Doctor: The Role of the Chief Medical Officer, 1855–1998 (Oxford: Radcliffe, 2005); V. Berridge, D. A. Christie, and E. M. Tansey (eds), Public Health and the 1980s and 1990s: Decline and Rise? (London: Wellcome Trust Centre for the History of Medicine, 2006). 24. D. Gittins, Madness in Its Place: Narratives of Severalls Hospital, 1913–1997 (London: Routledge, 1998). 25. M. Thomson, Psychological Subjects: Identity, Culture, and Health in Twentieth-Century Britain (Oxford: Oxford University Press, 2006); J. Moncrieff, The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (Basingstoke: Palgrave Macmillan, 2008); J. Swazey, Chlorpromazine in Psychiatry: A Study of Therapeutic Innovation (Cambridge, MA: MIT Press, 1974). 26. N. Crossley, ‘Transforming the Mental Health Field: The Early History of the National Association for Mental Health’. Sociology of Health and Illness 20 (1998), 458–88; A. Mold and V. Berridge, Voluntary Action and Illegal Drugs: Health and Society in Britain since the 1960s (Basingstoke: Palgrave Macmillan, 2010). 27. D. Healy, The Antidepressant Era (Cambridge, MA: Harvard University Press, 1997); D. Healy, The Creation of Psychopharmacology (Cambridge, MA: Harvard University Press, 2002). 28. V. Quirke, Collaboration in the Pharmaceutical Industry: Changing Relationships in Britain and France, 1935–65 (New York: Routledge, 2008); T. Pieters, Interferon: The Science and Selling of a Miracle Drug (Abingdon: Routledge, 2005); J. Goodman and V. Walsh, The Story of Taxol: Nature and Politics in the Pursuit of an Anti-cancer Drug (Cambridge: Cambridge University Press, 2001); P. Keating and A. Cambrosio, Biomedical Platforms: Realigning the Normal and the Pathological in Late Twentieth Century Medicine (Cambridge, MA: MIT Press, 2003). 29. A. Daemmrich, Pharmacopolitics: Drug Regulation in the United States and Germany (Chapel Hill: University of North Carolina Press, 2004). 30. J. Stanton (ed.), Innovations in Health and Medicine: Diffusion and Resistance in the Twentieth Century (London: Routledge, 2002); J. Stanton, ‘The Cost of Living: Kidney

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Dialysis, Rationing and Health Economics in Britain, 1965–1996’, Social Science and Medicine 49 (1999), 1169–82. 31. S. de Chadarevian and H. Kamminga (eds), Molecularising Biology: New Practices and Alliances, 1910s–1970s (Amsterdam: OPA, 1998). 32. L. Bryder, A History of the ‘Unfortunate Experiment’ at National Women’s Hospital (Auckland: Auckland University Press, 2009); eadem, Women’s Bodies and Medical Science: An Inquiry into Cervical Cancer (Basingstoke: Palgrave Macmillan, 2010). 33. J.-P. Gaudilliere and I. Lowy, ‘Science, Markets and Public Health: Contemporary Testing for Breast Cancer Predisposition’, in V. Berridge and K. Loughlin (eds), Medicine, the Market and the Mass Media: Producing Health in the Twentieth Century (Abingdon: Routledge, 2005), 266–88; L. Berlivet, ‘Uneasy Prevention: The Problematic Modernisation of Health Education in France after 1975’, in Berridge and Loughlin (eds), Medicine, the Market and the Mass Media, 95–122. 34. L. Marks, ‘ “Not Just a Statistic”: The History of USA and UK Policy over Thrombotic Disease and the Oral Contraceptive Pill, 1960s- 1970s’, Social Science and Medicine 49 (1999), 1139–55; L. Bryder. ‘ “We Shall Not Find Salvation in Inoculation”: BCG Vaccination in Scandinavia, Britain and the USA, 1921–1960’, Social Science and Medicine 49 (1999), 1157–67; U. Lindner and S. Blume, ‘Vaccine Innovation and Adoption: Polio Vaccines in the UK, the Netherlands and West Germany, 1955–65’, Medical History 50 (2006), 425–46; I. Lowy and J. Krige (eds), Images of Disease: Science, Public Policy and Health in Post war Europe (Luxembourg: Office for Official Publications of the European Community, 2001). 35. T. Brown and E. Fee, ‘The World Health Organisation and the Transition from “International” to “Global” Public Health’, American Journal of Public Health 96 (2006), 62–72; S. S. Amrith, Decolonising International Health: India and South East Asia, 1930–65 (Basingstoke: Palgrave Macmillan, 2006); P. Greenough, ‘Intimidation, Coercion and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973–5’, Social Science and Medicine 41 (1995), 633–45; S. Bhattacharya, Expunging Variola: The Control and Eradication of Smallpox in India, 1947–77 (London: Sangam, 2006). 36. M. Gorsky, ‘The British National Health Service, 1948–2008: A Review of the Historiography’, Social History of Medicine 21 (2008), 37–60. 37. I. Loudon, J. Horder, and C. Webster (eds), General Practice under the National Health Service (Oxford: Clarendon Press, 1998); A. Cutler, ‘Dangerous Yardstick? Early Cost Estimates and the Politics of Financial Management in the First Decade of the National Health Service’, Medical History 47 (2003), 217–38. 38. J. Daly, Evidence-Based Medicine and the Search for a Science of Clinical Care (Berkeley: University of California Press, 2005); J. Welshman, ‘Ideology, Social Science and Public Policy: The Debate over Transmitted Deprivation’, Twentieth Century British History 16 (2005), 306–41; Berridge (ed.), Making Health Policy. 39. J. Mohan, Planning, Markets, and Hospitals (London: Routledge, 2002). 40. V. Berridge and S. Blume (eds), Poor Health: Social Inequality before and after the Black Report (London: Frank Cass, 2003); the witness seminar on Griffiths management reforms is available at www.lshtm.ac.uk/history 41. D. Cantor (ed.), Cancer in the Twentieth Century (Baltimore: Johns Hopkins University Press, 2008). 42. G. Rivett, From Cradle to Grave: Fifty Years of the NHS (London: Kings Fund, 1998).

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43. K. Loughlin and V. Berridge, ‘Whatever Happened to Health Education? Mapping the Grey Literature Collection Inherited by NICE’, Social History of Medicine 21 (2008), 561–72. 44. J. Foster, AIDS Archives in the UK (London: London School of Hygiene and Tropical Medicine, 1990); for further discussion of oral history, see Chapter 33 by Kate Fisher, in this volume. 45. R. Klein, The New Politics of the National Health Service from Creation to Reinvention, 5th edn (Oxford: Radcliffe, 2006). 46. Virginia Berridge, ‘Hidden from History?: Oral History and the History of Health Policy’, Oral History, 38 (2010), 91–100. 47. Berridge and Blume (eds), Poor Health. 48. D. Courtwright, ‘Drug Wars: Policy Hots and Historical Cools’, Bulletin of the History of Medicine 78 (2004), 440–50. 49. D. J. Rothman, ‘Serving Clio and Client: The Historian as Expert Witness’, Bulletin of the History of Medicine 77 (2003), 25–44. 50. http://www.historyandpolicy.org, accessed 6 January 2010. 51. V. Berridge, ‘Public or Policy Understanding of History?’, Social History of Medicine 16 (2003), 511–23. 52. V. Berridge, ‘History Matters? History’s Role in Health Policy Making’, Medical History 52 (2008), 311–26. 53. The Wellcome film project will help with online access: http://library.wellcome.ac.uk/ doc_WTX058737.html, accessed 6 January 2010. See also the discussion by Tim Boon in Chapter 34. 54. Nancy Tomes, ‘ “Skeletons in the Medicine Closet”: Women and “Rational Consumption” in the Inter-war American Home’, in Mark Jackson (ed.), Health and the Modern Home (New York: Routledge, 2007), 177–95.

Select Bibliography Berridge, V., Health and Society in Britain since 1939 (Cambridge: Cambridge University Press, 1999). —— , AIDS in the UK: The Making of Policy, 1981–1994 (Oxford: Oxford University Press, 1996). Cantor, D. (ed.), Cancer in the Twentieth Century (Baltimore: Johns Hopkins University Press, 2008). Cooter, R., and J. Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000). Fee, E., and D. Fox (eds), AIDS: The Burdens of History (Berkeley: University of California Press, 1988). —— , and —— , AIDS: The Making of a Chronic Disease (Berkeley: University of California Press, 1992). Gorsky, M., ‘The British National Health Service, 1948–2008: A Review of the Historiography’, Social History of Medicine, 21 (2008), 37–60. Lowe, R., The Welfare State in Britain since 1945 (Basingstoke: Palgrave Macmillan, 2005). Webster, C., The Health Services since the War, 2 vols (London: Stationery Office, 1988–96). —— , ‘Conflict and Consensus: Explaining the British Health Service’, Twentieth Century British History, 1 (1990), 115–51.

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chapter 8

gl oba l a n d loca l h istor i e s of m edici n e : i n ter pr etati v e ch a l l enge s a n d fu t u r e possibilitie s s anjoy bhattacharya

References to global perspectives in medical history have been commonplace in recent years. At the same time, there has been little unanimity about what the concept ‘global’ means. Sometimes interchangeably used with terms such as ‘transnational’ and ‘international’, the term ‘global’ has been used by academics to propound a variety of different conceptual paradigms. For some historians, a focus on globality involves studying the attitudes and actions of individuals who worked both within and outside the confines of formal structures of governments within empires or nation-states. Studying a variety of themes and straddling a broad temporal frame, several of these works have dealt with the thoughts and actions of institutions and individuals in exploratory missions that helped fortify efforts to conquer territories and entrench mercantile interests,1 as well as attitudes amongst members of migrant and settler communities as they entered into complex sets of engagements with multiple sponsors and pre-existing social frameworks in newly acquired possessions.2 Other scholarship, generally dealing with developments at different points of the twentieth century, has tried to define global history as a theme requiring study of the agency of private individuals and organizations across relatively porous political borders of empires and nations.3 Some of this work examines socioeconomic connections between Europe, the United States of America, and their respective zones of influence through the dissemination and translation of tropical medicine.4 Other elements of this historiography present long-term studies of specific diseases and programmes intended to limit their spread,5 while there are those who describe the role of private enterprise in developing multifaceted and multidirectional trading

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arrangements in medicinal products.6 There is another important strand in medical histories that have adopted a global perspective—a genre of work that examines the roles played by different United Nations organizations, such as the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), in national and international health programmes in the post-Second World War era (often in association with Scandinavian aid and development programmes).7 All in all, this work is marked by a great diversity in research focus and mode of analysis. Although the historiography is rich and has generally succeeded in making us aware of a variety of important new themes and issues, it is difficult to ignore limitations in perspective. The professed views and actions of a relatively small number of people are frequently used to describe the workings of large, complex formations: imperial edifices, national governments, and non-governmental organizations, as well as multifaceted social and political structures. Elitist and selective notions of globality and internationalism are the result, especially when medical trends and the unfolding of international health programmes in the developing world—or the ‘global south’—are examined in constricted ways. A reliance on the voices of actors occupying senior positions in international agencies and national governments has caused scholars to either disregard or downplay local agency. This, in turn, has led their works to ignore the important point that contradictory visions coexisted at all points of time, within both state and society.8 These trends are perhaps explicable by the fact that the recognition of ideological and practical variations in the field has the capacity to destabilize the cosy generalizations upon which some of the most simplistic notions of global history are built. Simply put, historians of global medical history need to work harder to bring in a wide cross-section of voices in their studies. Rather than assuming that one set of visions was always able to displace and dominate others, and that this resulted in the development and deployment of largely unified modes of practice, it might be more meaningful to develop complex analyses that assess the impact of the persistence of variations in the provision of health services. The challenge, therefore, is to develop conceptual frameworks that allow us to incorporate analyses of large numbers of opinions and to better understand how this affected trends in medicine and public health. Indeed, it is crucial that historians recognize the significance of mapping out a complex mosaic of theory and practice, wherein ideas were exchanged and often unrecognizably transformed (rather than just transmitted by one party and unquestioningly accepted by another), and different approaches to policy implementation remained fluid and often interdependent (rather than being monolithic and unchanging, based on the views of a specific constituency). This chapter attempts to develop a more inclusive set of conceptual frameworks for global histories of health and medicine. It is based on the assessment of a very wellknown global story: the programme to eradicate smallpox. It is a case study worthy of analysis, not merely because it has been well chronicled and rich archival resources are available, but also because its histories have been particularly prone to narrow notions of globality, primarily based on heroic descriptions of the roles played by relatively small groups of workers. This chapter consciously avoids being overly reliant on the published and publicly expressed views of a handful of senior officials attached to the WHO offices

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in Geneva. Instead, an effort is made here to study a variety of voices and to examine how a diversity of people carried out intricate negotiations with different political and social constituencies and helped to expunge variola. The approach here, which is also recommended as a mode of research, is to go behind the scenes to study views expressed in private, and then assess how the resulting convictions, discussions, and debates impacted on the unfolding of policy.

Troubled preparations for global smallpox eradication If some retrospective writings are taken at face value, one could be forgiven for thinking that the so-called intensified phase of the global smallpox eradication programme was well under way in 1969.9 Enthusiastic descriptions of developments are not completely unwarranted. At one level, developments within the Geneva office, from 1969 onwards, were quite striking. Where there had been widespread division, doubt, and apathy amongst senior WHO officials in the early 1960s, the situation was substantially more promising by the end of the decade. The smallpox eradication unit began to receive better financial backing from the WHO budget, its officials were allowed to set up and run a dedicated fund from within the confines of the organization’s headquarters (HQ) and, perhaps most importantly, the unit’s managers were being more openly supported by the Director General’s office in their efforts to raise money, personnel, and vaccine for the ambitious projects planned for Asia and Africa. However, things were less rosy at other levels. Negotiations with national administrations were seldom smooth and agreements tended to be transient. Notably, WHO representatives had to reconcile themselves to paying a stiff price during their consultations with the Indian federal authorities in the period between 1967 and 1968. The retention of the Indian chapter in the global smallpox eradication programme was guaranteed only after the WHO HQ promised significant infrastructural support, intended to help run the so-called intensified campaign in the country on a day-to-day basis. Some early estimates suggested that the WHO would have to meet 50 per cent or more of these expenses, with national budgets making the rest of the necessary money and infrastructure available; most Indian officials expected the WHO to meet at least half of all the programme costs, but kept hoping for more money.10 Yet, such gestures of generosity were not easily made by the WHO in the face of severe resource crunches, especially in relation to the global smallpox eradication programme; this was symptomatic of a situation where WHO negotiators continually struggled to convince donors to provide prolonged support. Indeed, the Geneva-based smallpox unit struggled in 1967 and 1968 to identify adequate producers and stocks of freeze-dried vaccine for the anticipated needs of a global campaign.11 For this reason, the WHO HQ expected national governments, like those of India and Pakistan, to enter into bilateral

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aid agreements with a variety of funding agencies, with the purpose of raising significant stocks of smallpox vaccine and money for making more health workers available in the field.12 Apart from anything else, such problems made WHO negotiators keenly aware of the need to mobilize the support of governments of high-income countries on a continuing basis; several prolonged consultations resulted, which generated their own share of complications. Most of the rich, industrialized nations had already managed to eradicate smallpox within their territories through a variety of vaccination, isolation, and surveillance regimes. This led several European and American political leaders to wonder whether it was necessary or prudent to get involved in financing a worldwide programme aiming to stamp out the disease. To make matters worse, there was widespread doubt within donor nations about whether it was really ever possible to eradicate variola.13 In circumstances such as these, several incidents involving the importation of smallpox into Europe proved to be a strategic blessing for WHO negotiators.14 These cases allowed advocates of smallpox eradication to point out, during consultations with governments and aid agencies, that no part of the globe was safe from variola. Smallpox, they argued convincingly, could be transmitted by the increasing numbers of people travelling by air, as well as those able to move across many miles of unregulated national political boundaries across the world. The possibility that variola might return—in both epidemic and endemic forms—to countries that had previously managed to get rid of the disease was frequently highlighted during negotiations. The presentation of such grim scenarios did not go unnoticed by European and American governments; countries such as the United States kept nervously eyeing the situation all over the world and its officials were particularly concerned by smallpox importations into Western Europe, due to the large numbers of air-travellers going in and out of the region.15 Official apprehension about the possible re-entry of the disease into Europe and the Americas was stoked further by a realization that an entire generation of public health and medical workers was lacking in first-hand knowledge about the symptoms of the disease and the challenges of interrupting its spread through specialized isolation regimes. These anxieties were revealed, amongst other things, through governmental negotiations with WHO offices located within regions with endemic smallpox; these aimed to provide members of their public health and medical services access to smallpox cases and practical training in the running of isolation units.16 Fears about the uncontrolled spread of smallpox did not, of course, automatically translate into institutional and financial support for the proposed programme to eradicate the disease. In a situation where the WHO HQ remained disunited for a long time about the wisdom of launching such an ambitious project, national funding agencies baulked at providing high levels of support on a consistent basis; instead, high-income nations invested more and more money in the development of surveillance and containment regimes in airports, shipping ports, and railheads, with the aim of identifying smallpox in travellers and keeping them away from the general population. Although expensive, the system was hardly foolproof: as case after case showed, these surveillance networks were unequal to the task of stopping the entry of variola infections, especially

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where people managed to get through the controls with falsified vaccination certificates, where indicators of the disease were missed by inspectors, and where individuals carried the disease across unregulated borders.17 Interestingly, the tide of donor disinterest began to turn from the late 1960s, when the WHO’s complex structures began to fall in line, at least publicly, behind calls for the reinvigoration of national smallpox eradication campaigns and the interlinking of all this work on an international and regional basis. This unity was well exemplified by the WHO HQ’s increasing willingness to highlight the long-term financial benefits of eradicating smallpox globally through a variety of high-profile events. The World Health Day celebrations of 1966 were a notable example; these sought to raise awareness about the dangers from smallpox importations and highlighted the usefulness of eradicating the disease. One of the messages underlined at this event was to be repeated over and over again in the future, especially during negotiations with government representatives associated with high-income donor nations and the countries regarded as major reservoirs of smallpox: it made sense to spend money on an expensive, drawn-out global eradication programme, as this investment would be returned many times over through the financial savings made by dismantling structures for regular surveillance, containment, and vaccination. Remarkably, senior WHO officials—including those driven by the urge to prevent painful deaths from a damaging disease—recognized the ability of this line of reasoning to attract the attention of hard-nosed national administrators and loosen their budgetary purse-strings.18 Discussions held with agencies such as the US Agency for International Development (USAID) and the Swedish International Development Agency (SIDA) provide good examples of such trends; it is worth noting that the monies made available by these agencies in the first half of the 1970s were crucial to the expansion of the South Asian national smallpox eradication campaigns that were the cornerstone of the global campaign. It is also notable that almost all of these negotiations were time-consuming and were characterized by complicated twists and turns. This situation was mainly a product of the repeated overshooting of advertised timetables in focus areas such as India and East Pakistan/Bangladesh, and the resultant delays in the global programme; these operational difficulties kept stoking donor doubts about providing continued support, which could ultimately only be assuaged through a series of delicate consultations. Strikingly, these involved efforts to cajole—and sometimes also to frighten—funding agencies through suggestions that smallpox epidemics might uncontrollably spread across political borders. A good case in point was the manner in which D. A. Henderson, Chief of the WHO Smallpox Eradication Unit, dealt with senior SIDA officials in Stockholm in 1973, when he was seeking to justify a request for an additional US$6 million for completion of work in India and Bangladesh: During the last two years, importations from the remaining endemic countries have occurred in smallpox-free countries such as Japan and the United Kingdom, and in 1972, the return of infected pilgrims from Iraq resulted in an epidemic in Yugoslavia.

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In spite of the controls imposed by health authorities on international travellers, every country is in danger until the last case of smallpox has been eliminated. The world’s hope of eliminating the disease in 1974 is centred on the intensified campaign being carried out in the last four endemic countries. Particular attention is focussed on India and Bangladesh where logistics present special problems. Both these countries’ governments have given their full support to this crash programme and the campaign has already given impressive results. But, we are now faced with great difficulties due to the increased price of petrol, insufficient transport facilities, and the lack of funds necessary for the provision of high-level supervisory staff. So as to avoid a serious cutback in the programme at this crucial stage when so many national and international efforts are being made to assure its success, the support of SIDA in the form of a contribution to the Special Account for the Smallpox Eradication Programme of the World Health Organisation would provide invaluable assistance at this vital time and would help to insure the realisation of the global eradication of smallpox.19

This fund-raising exercise was a success and it provided a crucial lifeline for the work being carried across the South Asian subcontinent.20 Interestingly, this was not the last time that SIDA would be approached by the WHO HQ with entreaties for further assistance. As the Indian and Bangladeshi programmes continued well into the mid-1970s, senior Geneva-based officials were to turn to the agency for more money. One of these requests was sent in during the summer of 1974, when an unexpected outbreak of smallpox in Bihar threatened to destroy all the gains of the past years.21 SIDA provided an emergency infusion of funds at this juncture, not least as its officials did not want to see the considerable investments made in the global eradication programme go to waste.22 And, as the global smallpox eradication programme continued into 1975, 1976, and 1977, its managers struggled to cope with continual financial difficulties. While it had been relatively easy to raise emergency funds to cope with serious outbreaks of variola, it was more difficult to convince donors to assist a programme that had kept missing declared timetables. Indeed, senior WHO officials began referring to instances of ‘donor fatigue’, causing people like Henderson to approach new organizations—such as the Canadian International Development Agency—for additional financial assistance to complete projects in India, Bangladesh, and Ethiopia.23 The WHO negotiators’ efforts to mobilize aid in the form of vaccine stocks were no less complicated. At one level, they comprised extended consultations with various national governments about their willingness to donate vaccines to a special, voluntary ‘account’ maintained in Geneva. Created over time to meet the day-to-day needs of the global programme, as well as emergency requirements worldwide, this ‘account’ was the product of gifts of vaccine received from the USSR, USA, Britain, France, Denmark, Brazil, Switzerland, Sweden, West Germany, the Netherlands, Kenya, Finland, and a host of other countries in the late 1960s and the early 1970s.24 Officials based within the WHO HQ maintained a further set of dealings with an international network of laboratories, whose facilities were used for the testing of the potency and safety of different batches of vaccine being readied for release in the field.25 These dealings were not trouble-free. At different points of time in the late 1960s and 1970s, major donors like the USSR were

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unable—or perhaps unwilling—to provide the numbers of vaccine required by WHO departments supporting national smallpox eradication campaigns in Asia and Africa. Indeed, the Soviet authorities often preferred, in an effort to raise political goodwill, to supply vaccine through bilateral arrangements with national governments (India, for instance, received hundreds of millions of doses from the USSR in bilateral aid packages). In such a situation—especially in contexts where emergency anti-smallpox measures were being concurrently deployed in different parts of the world—there were instances where donations of vaccine were hurriedly accepted and distributed, and then found to be ineffective or capable of inflicting serious complications. A notable example occurred in 1972, when the WHO HQ sent stocks of vaccine gifted by the Yugoslav Government to Zambia. Certain batches of these prophylactics, which had been produced at the Institute of Immunology at Zagreb, were found to be capable of causing post-vaccinal encephalitis; to the great chagrin of all involved, these vaccines ended up being responsible for a couple of deaths in the African nation. The product was quickly withdrawn, but this experience taught senior WHO HQ officials some important lessons that were not forgotten for a long time; from this point onwards, more money, time, and effort was spent on the arrangement of independent checks on all vaccines donated for use in the global smallpox eradication programme and secondary investigations were frequently carried out on batches earmarked for release in the field.26

National governments, WHO negotiations, and global smallpox eradication It is clearly evident that prolonged interactions between WHO officials and different administrative agencies in countries with active smallpox eradication campaigns formed an important facet of the global programme. These dealings hinged on a number of important issues. In the face of continual resource constraints in the 1970s, discussions about the provision of extra funding for smallpox eradication loomed large in official deliberations. WHO administrators encouraged national governments to raise additional money from other countries and their aid agencies, through a series of bilateral arrangements. An interesting exchange in this regard occurred in 1973 between WHO South East Asia Regional Office (SEARO) operatives and the smallpox eradication unit in Geneva. The officials in the regional office were aware of negotiations between the United States and Indian federal authorities for the utilization of Rs. 2,600 crores (US$4 billion, at the exchange rates prevalent at the time), a fund that the former had developed through the sale, in rupees, of wheat to the subcontinent. While they were keen that at least some of these funds be used to buttress the national smallpox eradication programme budget, it was recognized that negotiations were likely to be protracted, difficult, and possibly unsuccessful.27 It is important to remember here that many aid

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packages were discussed and finalized by political leaders without the knowledge of WHO officials, which meant that they had minimal amounts of influence on the ways these monies were distributed and used by national and local authorities. These aid packages were highly politicized, as they were deeply affected by prevalent administrative, economic, and social interests in ‘donor’ and ‘recipient’ countries; great efforts were, therefore, made by the latter to ensure that these funds were deployed ‘autonomously’, without any sort of external direction or interference. Interestingly, records of bilateral negotiations carried out with nations decolonized in the 1960s and early 1970s reveal ambivalent attitudes within their governments towards WHO regional offices, even in a situation where they were keen to work in close association with the WHO HQ.28 These situations coexisted side by side with other funding trends. It is, for instance, notable that the Indian and Bangladeshi governments ended up helping the global programme out financially at crucial junctures, as in 1974, when the WHO special account for smallpox eradication had almost been exhausted. Senior WHO HQ officials telegraphed its workers in New Delhi and Dhaka at this time, asking them to approach the Indian and Bangladeshi federal authorities for an emergency infusion of funds; these requests were upheld, to the relief of those involved in managing different elements of the global programme.29 In India, for instance, the situation was rescued by her central government’s decision to release US$2.5 million of SIDA funds to the WHO special account; these monies had initially been given to New Delhi through a bilateral arrangement, for nationally sponsored smallpox eradication work.30 The persistent shortage of money also explains why senior WHO HQ officials supported efforts by the New Delhibased unit to raise resources locally, from both public and private financiers. The support mobilized with J. R. D. Tata’s help during the epidemic in Bihar state in 1974, which mobilized hundreds of extra health workers and doctors in the field, was a particular triumph; the aid provided by Tata ensured that the Indian and global programmes were not suddenly blown completely off course.31 Yet other staffing challenges further complicated already difficult administrative and political situations. As international workers were unable to carry out all search and containment missions on their own, they remained dependent on the support of all grades of national staff to run projects on a day-to-day basis throughout the late 1960s and 1970s. These personnel could only be mobilized with the assistance of national governments, which released workers from the central health services to keep national smallpox eradication programmes operational; federal backing also helped in efforts to bring provincial and district-level staff on side, even though these endeavours delivered mixed results in a situation where local workers retained a high degree of autonomy over their working lives. Uneven and shifting levels of administrative support for smallpox eradication projects resulted, which forced WHO workers to remain involved in an almost permanent condition of consultations with government officials in all national contexts. A direct outcome of this was the attempt on the part of the WHO HQ to deploy more international personnel for the management of touring search and containment teams in South Asia and East Africa, which were the focus of the global programme by the mid-1970s. However, this could not be done without the permission of national

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governments, even though several federal health department officials responded enthusiastically to the involvement of foreign epidemiologists and administrators on WHO contracts of varying lengths. In all cases, the prospective workers’ dossiers had to be submitted by the WHO HQ to national security agencies for examination, after which clearances were given to selected candidates; in addition, constraints were placed on the movements of international personnel, who were expected not to enter strategically sensitive areas without special permits. The sheer complexity of the attendant negotiations is best highlighted by the WHO’s experiences in relation to South Asia and the Horn of Africa. In the early 1970s, the Indian government announced that it would be unwilling to allow international personnel attached to the WHO into the politically sensitive region of North Eastern India, which was a region composed of the states of Manipur, Nagaland, Tripura, Mizoram, Meghalaya, Sikkim, and the North Eastern Frontier Agency (now renamed Arunachal Pradesh). This stunted the plan to deploy intensive searches in an area about which extremely little information was available, but it was still generally acknowledged by WHO officials that it would be necessary to allow the Indian authorities to dictate the terms for personnel deployment.32 Visible in territories of countries such as Bangladesh, Mozambique, and Somalia, opposition to international workers was by no means limited to sections of federal government—some elements of provincial and district administration opposed colleagues who favoured the introduction of large numbers of foreign workers and demanded a control in their numbers. Their objection to international involvement at national and local levels is attributable to a variety of factors. Some of this antipathy was politically motivated. In several countries, government officials or powerful politicians with socialist leanings opposed the influx of workers from the United States and Western Europe and insisted, quite successfully, on the formation of mixed teams composed of workers from many nationalities. Resentment at the presence of international workers was also a product of the increased supervision of district-level health work carried out by the touring smallpox eradication teams; for some government officials this limited the scope of profitable private practice, which was generally carried out in clear contravention of their contracts of employment. In other cases, district-level health staff argued, not without reason at times, that the linguistic and administrative support required by foreign epidemiologists and personnel detracted from the time they had to complete their daily tasks. Indeed, some observers have pointed out that sustained involvement in search and containment campaigns caused health worker ‘fatigue’, which impacted adversely on their day-to-day performance in the long run; however, it needs to be noted that some of this criticism was rooted in the ideology of primary health care, which was becoming increasingly powerful in international circles and within influential sections of the WHO.33 And at least some of the official resistance to the presence of international workers was a direct result of the dislike of campaigns of forcible vaccination that sometimes underpinned search and containment campaigns. Although relatively rare, news of such strategies spread far and wide, stoking hostility towards touring teams with foreign workers, ‘outsiders’ from urban centres, and ‘collaborators’ from inside the districts; the patterns and intensity of violent resistance were always variable, informed as they were

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by the interaction between a complexity of local racial, class, and gender considerations, and disparate sets of administrative and political agendas.34

Conclusion The idea that the worldwide smallpox eradication programme was based on a definite set of ideas and actions, of a relatively small number of individuals, is commonplace; it is also a myth.35 This chapter has highlighted the operational complexity of the global push to expunge variola. It aims to show how the regional, national, and local components of this multifaceted programme were important and consistently active sites of negotiation and adaptation, involving workers drawn from a variety of institutional and national backgrounds; their actions were deeply influenced by numerous political, economic, and social realities, which were in a constant state of flux. The underlying argument here is that it is not enough to study the interactions between a handful of select senior officials associated with the WHO’s Geneva HQ and national governments, and then assume that their instructions were unquestioningly implemented by large numbers of field operatives. On the contrary, the calculations and activities of personnel associated with different WHO offices and departments, national and local administrations, and, not least, representatives of various funding and aid agencies are deserving of detailed examination, as they left indelible imprints on the so-called global smallpox eradication programme. At the same time, it is also important to recognize some associated points: that the beliefs of a handful of officials could never be comprehensively imposed across intricate governmental or social settings and that a great variety of opinions existed side by side within all institutional contexts, resulting in a complexity of intermeshing policy decisions. As the evidence presented here suggests, the coexistence of a plethora of ideas and actions in the field fostered complex patterns of activity that dismayed some and pleased others. The patterns and dynamics of response varied from place to place, at every level of administration and society; it is noteworthy that people could adopt very different attitudes in public and private, and also change their attitudes and actions over time and place. The regional, national, and local chapters of the global smallpox eradication programme, therefore, never took the predetermined paths that some senior WHO and government officials hoped they would. The great challenge for the historian is to capture, in as rich detail as possible, the many intricacies of the worldwide efforts to eradicate variola; this alone would allow for the production of an inclusive global history of the run-up to an event widely presented as the greatest triumph of international public health cooperation in the twentieth century. This raises an important question. Are all available analyses of worldwide smallpox eradication efforts—and the many other international attempts to stamp out other diseases for that matter—‘global histories’? Not necessarily. A lot of the existing work is over-reliant on the voices of few individuals, whose views are then presented as being representative of the thoughts and actions of the vast majority of participants.

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Disagreement and disengagement with the view of this small group of people is usually described in overly simplistic terms, often as incidents of resistance generally evoked by a host of cultural predispositions. This analytical approach is also visible in studies more willing to recognize the ‘agency’ of local actors; this can be explained by the fact that local contributions are often studied through the public statements and writings of small numbers of individuals, without adequate explanations about who they might have represented in complex social formations and whether their views were supported or questioned within them. What we have available at the moment, therefore, are palpably limited examinations of the two ends of a disease eradication programme involving participants from all over the globe—the top levels of organizations like the WHO HQ and some ‘indigenous’ voices that are supposed to be representative of the attitudes of everyone not completely supportive of the goal to permanently banish smallpox. History writing is, of course, not a dispassionate exercise: the choice of objects and views being chosen for study is reflective of the historian’s own analytical priorities, worldview, and political position. The act of privileging the views of a handful of senior offcials within the WHO HQ or the Centers for Disease Control in the United States (CDC) could be said to be reflective of a Europe- or North America-centric approach, especially where simplistic assumptions are also made about the smooth diffusion of ideas from one part of the globe to the other. At best, such scholarship can be described as constrained global histories that manage to look at one of several important elements of multifaceted health programmes run on a collaborative basis by international organizations and complex national administrative setups; at worst, such historians are blinkered and exclusionary. Therefore, one can argue that the preparation of rounded global histories of international disease eradication and health promotion activities requires a ‘globalization’ of the historian’s vision. This is best described as a willingness to recognize the importance of studying the range of attitudes prevalent in the countries where health campaigns were implemented, at different levels of state and society. Increasing the complexity of a multilayered analysis of a public health project is not necessarily negative from an intellectual standpoint. The pursuit of a rounded, inclusive global history of smallpox eradication can provide insights into a host of unexpected and important developments, which, when carefully studied in all their rich intricacy, can reveal a range of important official and civilian voices, actions and experiences; in this way, such history-writing can contribute to the production of more policy-relevant scholarship.

Notes 1. For two fascinating studies within an impressive range of scholarship, see: Kapil Raj, Relocating Modern Science: Circulation and the Construction of Knowledge in South Asia and Europe, 1650–1900 (Basingstoke/New York: Palgrave Macmillan, 2007); Sujit Sivasundaram, Nature and the Godly Empire: Science and Evangelical Mission in the Pacific, 1795–1850 (Cambridge: Cambridge University Press: 2005).

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2. Cristiana Bastos, ‘Migrants, Settlers and Colonists: The Biopolitics of Displaced Bodies’, International Migration 46 (5) (December 2008), 27–54; Erica Wald, ‘From begums and bibis to Abandoned Females and Idle Women: Sexual Relationships, Venereal Disease and the Redefinition of Prostitution in Early Nineteenth-Century India’, Indian Economic and Social History Review 46 (January/March 2009), 5–25; Margaret Jones, ‘Heroines of Lonely Outposts or Tools of Empire? British Nurses in Britain’s Model Colony: Ceylon, 1878– 1948’, Nursing Inquiry 11 (3) (2004), 148–60. 3. Kai Khiun Liew, ‘Terribly Severe though Mercifully Short: The Episode of the 1918 Influenza in British Malaya’, Modern Asian Studies 41 (2) (2007), 221–52. 4. See, for instance: Randall Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007); and Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines (Durham, NC: Duke University Press, 2006). 5. See, for example: James L. A. Webb, Jr., Humanity’s Burden: A Global History of Malaria (Cambridge: Cambridge University Press, 2008); and Marcos Cueto, Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975 (Baltimore: Johns Hopkins University Press, 2007). 6. Guy Attewell, Refiguring Unani Tibb: Plural Healing in Late Colonial India (Hyderabad: Orient Longman, 2007); Maarten Bode, Taking Traditional Knowledge to the Market: The Modern Image of the Ayurvedic and Unani Industry 1980–2000 (Hyderabad: Orient Blackswan, 2008); Madhulika Banerjee, Power, Knowledge, Medicine: Ayurvedic Pharmaceuticals at Home and in the World (Hyderabad: Orient Blackswan, 2009). 7. Niels Brimnes, ‘Vikings against Tuberculosis: The International Tuberculosis Campaign in India, 1948–1951’, Bulletin of the History of Medicine 81 (2) (2007), 407–30; idem., ‘BCG Vaccination and WHOs Global Strategy for Tuberculosis Control 1948–83’, Social Science and Medicine 67 (5) (2008), 863–73; Sunniva Engh, ‘The Conscience of the World?: Swedish and Norwegian Provision of Development Aid’, Itinerario 33 (2009), 65–82. 8. Warwick Anderson, ‘Indigenous Health in a Global Frame: From Community Development to Human Rights’, Health and History 10(2) (2008), 94–108; Sunil Amrith, Decolonizing International Health: India and Southeast Asia, 1930–65 (Basingstoke: Palgrave, 2006). 9. R. N. Basu, Z. Jezek, and N. A. Ward, The Eradication of Smallpox from India (New Delhi: WHO SEARO, 1979). 10. Memorandum from D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, to Regional Director, WHO Regional Office for South East Asia [WHO SEARO], New Delhi, 24 July 1968, File 416, Box 193, World Health Organization/Smallpox Eradication Archives (WHO/SEA). 11. A general call made by the WHO Director General in July 1963 for gifts of free vaccine yielded disappointing results. Memorandum on Smallpox Eradication Special Account, WHO HQ, Geneva, 17 January 1964, File SPX-1, Box 545, WHO/SEA. Also see the letter from Ernest S. Tierkel, USAID, New Delhi, to D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, 4 April 1967, File 416, Box 193, WHO/SEA, and the memorandum from D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, to the Director, Communicable Diseases, WHO HQ, Geneva, 14 April 1967, File 416, Box 193, WHO/SEA. 12. For references to USAID assistance to the Indian national smallpox eradication programme, see, for instance, Report from the Ministry of Health, Government of India, 1962–63 (New Delhi: Government of India Press, n.d.), 8, Shastri Bhavan Library, New Delhi, India. The

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13.

14.

15.

16.

17.

18.

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press in India was well aware of the significant levels of assistance provided by USAID through the ‘PL-480’ programme (this fund was created by the US Government through rupee sales of wheat to India; the money thus raised was offered to the Indian authorities for various developmental projects). An influential national newspaper calculated that PL-480 assistance had added up to Rs. 1,483.7 crores by February 1965 (an equivalent of US$3115.7 million at the time). See, ‘PL-480 and India’, Hindustan Times (9 February 1965). For references to the earmarking of PL-480 funds for the development and the running of the Indian campaigns and the role of bilateral funding arrangements in sustaining other South smallpox eradication programmes, see letter from D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, to C. Mani, Regional Director, WHO SEARO, New Delhi, 4 August 1967, File 416, Box 193, WHO/SEA. See, for instance, memorandum from D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, to Regional Director, WHO SEARO, New Delhi, 24 October 1968, File 416, Box 193, WHO/SEA. As air travel became cheaper and quicker in the 1960s, European government officials noted that this mode of transport began to be used by growing numbers of people, especially by those based in ex-colonial and colonial territories to travel to imperial metropoles. See, for instance, minutes for meeting held at the British Ministry of Health (MoH) on 5 January 1962, MH 55/2520, The National Archives, Kew, UK (hereafter, TNA). Several cases of smallpox importations into Britain, from Pakistan, were reported in January 1962. This caused great nervousness within the British MoH, which feared that these cases could snowball into a major epidemic. See, for instance, statement released by the MoH, 12 January 1962, MH 55/2520, TNA. For good examples of US Government fears about cases of imported smallpox in Europe, see memorandum by J. G. Tefler, Chief, Division of Foreign Quarantine, US Government, to Chief, Epidemiology Branch, CDC HQ, Atlanta, 10 April 1962, Box 18875, Folder 14, Federal Record Center (FRC), East Point, Georgia, USA. The American media was, of course, not immune to such nervousness and the European smallpox outbreaks were reported by a variety of newspapers. See, for example, articles titled ‘British Rush For Smallpox Shots As Sixth Person Dies’, Atlanta Journal (15 January 1962), and ‘Smallpox Won’t Spread to US, Officials Say’, Washington Star (20 January 1962), in Box 124597, Folder 3, FRC. At another level, it is worth noting that reports of smallpox outbreaks in Britain caused international restrictions to be placed on travellers from the country, which was considered to be both embarrassing and disruptive. See, for example, telegram from Sir R. Black, British representative, Hong Kong, to Secretary of State for the Colonies, 3 March 1962, MH 55/2520, TNA. Memorandum from Director, Communicable Disease Section, WHO HQ, Geneva, to Regional Director, WHO SEARO, New Delhi, 28 October 1960, File SPX-1, Box 545, Smallpox Eradication Archives, WHO/SEA. For a representative assessment of cases where smallpox symptoms were not recognized by port medical officials in Europe, which, in turn, resulted in localized outbreaks of the disease, see letter from R. T. Ravenhoff, Consultant Epidemiologist, CDC HQ, Atlanta, to J. Buchness, Foreign Quarantine (Europe), US Government, 1 June 1962, in Box 124597, Folder 3, FRC. It is important to note this is a situation where speeches and writings by WHO officials about the long-term financial savings promised by global smallpox eradication have been taken far too literally by historians who downplay the variations in vision and policy

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19. 20. 21.

22. 23. 24. 25.

26.

27.

28.

29. 30. 31.

32.

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implementation within a complex organization. See, for instance, Harish Naraindas, ‘Charisma and Triage: Extirpating the Pox’, Indian Economic and Social History Review 40 (4) (2003), 425–58. ‘Draft Justification for Proposal to SIDA’, by WHO SEARO, New Delhi, c.1973, appendix to File 948, Box 17, WHO/SEA. Interview with Dr. D. A. Henderson, London, March 2007. Letter from D. A. Henderson, Chief, Smallpox Eradication Unit, WHO HQ, Geneva, to Mr. R. Lickfett, Senior Programme Officer, SIDA, Stockholm, Sweden, 1 July 1974, File 948, Box 17, WHO/SEA. Interview with Dr. D. A. Henderson, London, March 2007. Letter from D. A. Henderson, WHO HQ, Geneva, to Mr. R. Binnerts, Connaught Laboratories, Canada, 24 June 1975, File 586, Box 321, WHO/SEA. For communications exchanged between the WHO HQ and WHO regional offices with a range of national donors in the first half of the 1970s, see File 240, Box 304, WHO/SEA. A select few—like the Rijks Institute based in Utrecht in the Netherlands, the Connaught Laboratories in Canada, and the Lister Institute of Preventive Medicine in Britain—were asked for assistance in the 1970s on a regular basis and, therefore, accorded the status of ‘WHO reference laboratories’. See, for instance, the memorandum from Dr. Isao Arita, WHO HQ, Geneva, to Director, WHO Eastern Mediterranean Regional Office, Alexandria, 5 May 1970, File586, Box 321, WHO/SEA, and the letter from Dr. R. J. Wilson, Chairman and Director, Connaught Laboratories Limited, Ontario, Canada, to Dr. Ruperto Huarta, Chief, Communicable Diseases Section, Pan American Health Organization, Washington, DC, 29 January 1975, File 586, Box 321, WHO/SEA. See restricted report on field trial of reactivity of smallpox vaccines (Krapina community), c.1973, attached to letter from Professor D. Ikic, Director, Institute of Immunology, Zagreb, Yugoslavia, to D. A. Henderson, WHO HQ, Geneva, 26 June 1973, File 240, Box 304, WHO/SEA, and restricted memorandum from D. A. Henderson, WHO HQ, Geneva, to Director, WHO AFRO, 11 July 1973, File 240, Box 304, WHO/SEA. Personal letter from Dr. L. B. Brilliant, WHO SEARO, New Delhi, to D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, 20 July 1973, File 388, Box 194, WHO/ SEA. See, for instance, ‘unsanitized’ [sic] minutes on a meeting between Peter C. Bourne and an unnamed doctor representing Mozambique at the World Health Assembly of 1977 in WHO HQ, Geneva, Switzerland, US Department of State, Document issue date: 1 May 1977, Date of declassification: 11 December 1996, Document Number CK3100097424, Declassified Documents Reference System, Cambridge University, UK. WHO HQ and WHO SEARO, 4 March 1974, File 948, Box 17, WHO/SEA. Memorandum from D. A. Henderson, Chief, Smallpox Eradication, WHO HQ, Geneva, to Dr. L. Bernard, WHO HQ, Geneva, 7 March 1974, File 948, Box 17, WHO/SEA. Personal letter from Dr. L. B. Brilliant, Medical Officer, WHO SEARO, New Delhi, to Mr. J. R. D. Tata, Tata Industries Private Ltd., Bombay, 25 June 1974, File 388, Box 194, WHO/SEA, and personal letter from Mr. J. R. D. Tata, Tata Industries Private Ltd., Bombay, to Dr. L. B. Brilliant, Medical Officer, WHO SEARO, New Delhi, 28 June 1974, File 388, Box 194, WHO/SEA. The nationalities represented amongst WHO SEARO staff in India in 1973 were as follows: USSR, USA, Czechoslovakia, Mexico, Brazil, Singapore, and France. See memorandum, WHO SEARO, New Delhi, c.1973, File 388, Box 194, WHO/SEA. For a description of the

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surveillance work planned and conducted in Bhutan in the 1970s, see File 826, Box 192, WHO/SEA. 33. National and local government administrators would often point out that the arrival of international workers increased their workload, as this required them to provide a variety of support services while also looking after their pre-existing responsibilities. A good assessment of these trends is provided in the unsanitized minutes on a meeting between Peter C. Bourne and Mr. Rabile, Minister of Health, Somalia, at the World Health Assembly of 1977 in WHO HQ, Geneva, Switzerland, US Department of State, Document issue date: 1 May 1977; Date of declassification: 11 December 1996; Document Number CK3100097516, Declassified Documents Reference System, Cambridge University Library, UK. 34. Sanjoy Bhattacharya, Expunging Variola: The Control and Eradication of Smallpox in India, 1947–77 (Hyderabad: Orient Longman: 2006). 35. See, for instance, Ian Glynn and Jennifer Glynn, The Life and Death of Smallpox (Cambridge: Cambridge University Press, 2004).

Select Bibliography Bastos, Cristiana, Global Responses to AIDS: Science in Emergency (Bloomington: Indiana University Press, 1999). Bhattacharya, Sanjoy, Expunging Variola: The Control and Eradication of Smallpox in India, 1947–77 (Hyderabad: Orient Longman, 2006). Brimnes, Niels, ‘Vikings against Tuberculosis: The International Tuberculosis Campaign in India, 1948–1951’, Bulletin of the History of Medicine 81 (2) (2007), 407–30. ——, ‘BCG Vaccination and WHOs Global Strategy for Tuberculosis Control 1948–83’, Social Science and Medicine 67 (5) (2008), 863–73. Cueto, Marcos, Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975 (Baltimore: Johns Hopkins University Press, 2007). Engh, Sunniva, ‘The Conscience of the World?: Swedish and Norwegian Provision of Development Aid’, Itinerario 33 (2009), 65–82. Packard, Randall, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007). Webb Jr., James, Humanity’s Burden: A Global History of Malaria (Cambridge: Cambridge University Press, 2008).

chapter 9

chi n e se m edici n e v ivienne l o and m ichael s tanley-baker

Those active in living traditions of medicine, either as practitioners or patients, have often imagined a long empirical tradition stretching back to a golden age in pre-history. Historians and anthropologists have too easily identified the essential characteristics of the medicine of a specific place, even when that place, particularly in the case of China, has been geographically and culturally diverse. In contrast, new research is more concerned in teasing out more complex dynamics between continuity and change as traditions constantly reinvent themselves in order to remain relevant, appropriate, and effective. Excavated records recovered from Shang dynasty (traditional dates: 1766–1122 bce) archaeological sites do indeed testify to very early divinatory techniques for identifying the cause and progress of illness, which is attributed to the malevolence of spirit ancestors.1 Yet while modern forms of ‘traditional Chinese medicine’ (TCM) bear the marked vestiges of astro-calendrical divinatory traditions, concerted attempts have been made in the twentieth century to eradicate its most obviously religious aspects. In the half-century since Needham began his project to write a history of science, technology, and medicine in China in its fullest social and intellectual context, the approaches of social and cultural historians have provided new tools to unlock the many dimensions of more popular (that is, pervasive) or religious healing practices. New evidence from texts written on bamboo and silk recently excavated from late Warring States (fourth to second centuries bce) and Han dynasty (202 bce–220 ce) tombs has also upset the traditional narratives that sourced the origins of medicine in the word of the legendary Yellow Emperor, 5,000 years ago.2 With these first medical treatises, set down in the late Warring States, we have a direct window onto the circumstances within which classical medical knowledge and practice first emerged. These new sources add depth and richness to the 10,000 extant pre-Communist (to 1949) medical works listed in the 1991 National Chinese Medicine Union Catalogue. This chapter does not attempt to describe the ‘evolution’ of a single entity that some imagine Chinese medicine to be. From a discussion of its mythic origins, through the coalescence of many theories about astro-physiology in early China to the medieval

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heyday of religious healing pluralism, it charts the changing emphases in what was always a plural healing environment. Indeed the ethnic and cultural boundaries of China itself are contested. Nevertheless there are clearly elements that pervade the scholarly and religious medicine of the Chinese empire. Most vividly, the extension of imperial bureaucracy reached into the body, whether controlling the body’s fluids as if they were the imperial waterways, imagining the organs as officials, or submitting petitions for cure to deity-officials in the afterlife. The rupture of imperial authority at the hands of foreign aggression, contemporaneous with the large-scale arrival of European and American doctors and scientists, promised to ring the death-knell for Chinese healing traditions. Yet they have continued to prove tenacious at reinventing themselves according to the ever-changing social and political priorities of the twentieth and twenty-first centuries. We conclude with some observations about how the sensory modalities of Chinese medical thought speak powerfully to a modern global audience who frequently feel their own individual experience of health and sickness devalued in the processes of modern standardized medicine.

Mythic origins and classical texts The beginning of imperial China is dated to 221 bce, when the military machine of Qinshi Huangdi 秦始皇帝 (259–210 bce), first emperor of the state of Qin, put an end to centuries of disunity during the Warring States period of the Zhou dynasty (1045–256 bce), and established the short-lived Qin dynasty (221–206 bce). With brutal efficiency, the Qin regime moulded a collection of small feudal kingdoms into a highly centralized imperial authority, broadly corresponding in geographic terms to what we know as China today. The Han dynasty (202 bce–220 ce), which came to power shortly after Qinshi Huangdi’s death, embraced the Qin’s realpolitik and forms of governance, but at the same time sought to distance itself from its influential but hated predecessor by drawing authority from the sage rulers of a golden age at the dawn of Chinese civilization, after whom the new administration was supposedly modelled. To this end, the myth-makers and history-writers of the Han retold the stories of the lost golden age for their own times. In traditional Chinese accounts, the origins of medicine and the claim to authoritative wisdom of the medical classics are ascribed to the revelations of sages and cultural heroes. The medical aspects of Chinese mythic history attest to the range of healing traditions that existed in early imperial China. The task of civilizing and domesticating a savage world fell to the five Sage Emperors, each of whom corresponded to one of the five directions: north, south, east, west, and centre.3 Two of them, the Yellow Emperor (Huangdi 黃帝), and the Red Emperor (Yandi 炎帝), also known as The Divine Farmer (Shennong 神農), are intimately associated with medicine and healing. Other mythic patrons of medicine include the ‘Medicine King’ Bian Que 扁鵲, sometimes represented as a human-headed bird, and the

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enigmatic Mr. White (Bai Shi 白氏). The names of these legendary figures occur repeatedly in the titles of medical texts, or as their putative authors. Cultural heroes are thus credited with formulating various ideas that are central to Chinese views of the world, the body, and human society. The legend of the Divine Farmer, in whose name the Shennong bencao jing 神農本草經 (Divine Farmer’s materia medica, c.first century ce) is written, enshrines the empirical spirit of Chinese medicine, and the concomitant belief that knowledge of the virtues of drugs and food had to be obtained through trial and error. The Divine Farmer’s main role was to rescue human beings from a state of savagery, where they fed on the raw flesh of the animals they hunted, drank their blood, and dressed in their skins, and to lead them towards an agrarian utopia. Famously, he tasted all living plants to ascertain their properties and, according to later accounts, struck all the plants with a magical whip to make them yield up their essential flavours and smells. He subsequently classified the plants and distinguished those that were safe and suitable for consumption and medicinal use. Testifying to the importance of this tradition of empirical testing, his name occurs in the titles of many famous materia medica texts. The best-known patron of medicine, the Yellow Emperor, is particularly associated with knowledge of how cosmic patterns were inherent in all things (laws, punishments, and the calendar) and he played a role in divination. These attributes link him with the specialized medical arts of understanding the body’s relationship with the cycles and phases of Heaven and Earth, and of accurately predicting the progress and outcome of disease. Prognostications regarding sickness and health were framed within numerological sequences first found in calendrical systems; thus the ‘Daybook’ (rishu 日書) divinatory calculations, which served to determine propitious times and places for human activities, became part of everyday health and hygiene practices.4 In China, medical practitioners were often literate, and their knowledge and practice can be reconstructed both from their own writings and from the written records of scholarly and religious traditions allied to medicine. Through 2,000 years of empire, the authority and competence of the Chinese state were constantly embodied in a multitude of texts generated by the organs of government at every level and medical practice was enmeshed in this bureaucratic process. Access to the upper echelons of the civil service was obtained via a succession of competitive examinations essentially testing mastery of the Confucian canons. An analogous hierarchy existed in scholarly medicine: increasingly, social status depended on the possession, knowledge, and authorship of written texts. In the course of the Han period, a vast corpus of medical knowledge came to be ascribed to the Yellow Emperor. Compilations known as jing 經 (translated as ‘classic’ or ‘canon’) set out many of the cardinal principles of Chinese medical theory.5 Today the Yellow Emperor corpus is now known only through three recensions based on a printed edition published in the twelfth century. The three texts differ in subject-matter, but together describe medical theory: the human body as a microcosm, the origins of disease, and some therapies, principally acupuncture and moxibustion (a form of cautery

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or heat treatment generally using artemisia vulgaris or mugwort), and a few drug prescriptions.6 Important treatises in the recension known as the ‘Numinous Pivot’ Lingshu 靈樞 are the earliest evidence for qi (the essential stuff of life that fuels and animates everything in the universe) moving round the body in a regular rhythm through channels called mo or mai (脈), a term variously translated as ‘channels’, ‘vessels’, ‘meridians’, or ‘pulse’. In the theory and practice of healing, those channels, concepts of qi, blood, and yin and yang current during the Warring States period were woven together and brought to bear on the human body. The mai were structural elements in a linear configuration of the inner body, foreshadowing the familiar tracts and channels of acupuncture. According to context, mai could refer to tracts underneath the skin (recognizable by the valleys between the raised ridges of the muscles), blood vessels, or the pathways of pain and other internal bodily sensations experienced as travelling or responding to palpation along a given plane. At certain locations on the surface of the body, the channels emerged in the form of pulses, which could be read for clues to the state of the body’s qi and the condition of the internal organs through which qi passed. Pulse diagnosis became the supreme diagnostic tool for elite medicine throughout the Chinese empire, and it retains primary importance for practitioners of TCM today. As Han physicians and thinkers came to grips with the puzzling behaviour of sickness, they were guided by a vision of a microcosmic body, united in its essence with the cosmos and the state, and inhabited by the same spirits, which lent it their potency. Just as qi connects every phenomenon in nature with the movements of the heavenly bodies and thus with the deities and the spirits of the ancestors, the imperial rulers aspired to extend their sway everywhere under heaven—and even to the body’s innermost depths where organs functioned as ministers of the empire, the heart as the ruler, the liver as the general. In an increasingly centralized state, the emperor played the crucial role of mediator between heaven and earth, which required him to carry out a cycle of complex rituals. Pursuing virtue, venerating one’s ancestors, and performing the rituals correctly were ways of securing the gods’ approval and ensuring order on earth. Disorder, in the form of civil unrest, natural disasters, famine, or disease, was a sign and consequence of the gods’ displeasure.7 The flow of qi around the body was like the flow of essential traffic through the network of roads and waterways that provided for the well-being of the Chinese empire. If the flow was blocked or disrupted, analogous consequences would ensue, and the same kinds of remedies were called for. By the Former Han period, in the last two centuries bce, this analogy was generally applied to a newly constructed acupuncture body with fourteen channels. For example, in Lingshu: 12 (Jing shui 經水), part of the Yellow Emperor’s Inner Canon, the acupuncture channels are correlated with natural water courses.8 In the literature of this formative era, we find a variety of theories about the number of channels, their paths, and their physical nature, in relation to ideas about circulation. Often, these theories reflect alternative views of celestial movements and the structure of Heaven and Earth. For instance, there are traces of an archaic number system based on the number eleven, in which the number six belongs to heaven and five to the earth.

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The treatises from the Yellow Emperor canon are mainly in the form of dialogues, which take place between the Yellow Emperor and a cast of learned ministers, including Lord Thunder (Leigong 雷公) and most notably the legendary minister Qibo 歧伯, who specialized in acupuncture and esoteric matters. In one dialogue, the Yellow Emperor asks Qibo about perceived contradictions in the ways in which the channels of the body reflect patterns in the heavens. In his reply, Qibo 歧伯 correlates particular days in the calendar with each channel.9 It is clear that the mai channels carried no fixed or pervasive numerical associations in early Han times, as inconsistencies are apparent in the assignation of time markers to organ systems and even to yin and yang. Dialogue form is frequently utilized in expository writing of the Han era as a device for exploring conflicting viewpoints and reconciling diverse ideas. By depicting the perfect architecture and rhythms of the human body with the same broad brush-strokes as the larger model of the cosmos, medical theorists were able to find intelligible structure in an inchoate mass of information, without which it would have been impossible to make predictions or to chart anomalies and sickness, but a single system was slow to emerge. The precursors of what is known today as ‘acupuncture’—the practice of adjusting bodily essences by the use of fine needles—emerged in the Han period out of a diverse range of healing arts: qi and yin and yang practices, numerology, divination, petty surgery, bloodletting, and aspects of spirit healing. The material origins of acupuncture are found in ‘medicinal stones’ or bian 砭,10 which by the beginning of the second century bce, were clearly being used with the specific aim of influencing the flow of qi along the mai channels so as to remove blockages believed to cause illness. An initial focus was fixed especially on locations where the channels crossed and the vicinity of the joints, where pain and discomfort were most frequently felt. Evidence for this therapy reveals an awareness of danger about the radical nature of this intervention. The ‘Jiu zhen’ 九鍼 (‘Nine Needles’) chapter of Lingshu records the Yellow Emperor criticizing the clumsy use of stone needles in qi therapy.11 Needles intended for moving qi were as slender as a fine hair and of very high quality, but most references in this text do indicate petty surgery or bloodletting rather than qi therapy as such. Chinese smiths certainly possessed the technology to produce very fine needles at this period, but no actual examples have survived. It is not until the first century ce that we find archaeological records of fine needles that can be linked with qi therapy at named acupuncture points. At all events, the use of needles still evoked a lingering disquiet even much later on.12 At the gentle end of the therapeutic spectrum, heat treatment or massage could be carried out at the blockage sites. Heat treatment tended to be regarded as a cheaper and more user-friendly alternative to needling, and the most widespread and most popular form of this was jiu 灸, translated as moxibustion. Moxibustion embraces a range of heat and cauterization techniques using various materials. It is sometimes spoken of as cauterization or cautery in the broad sense of the application of extreme heat, but it was used only occasionally to sear wounds. It has often been noted that anatomical research and dissection are conspicuous by their absence from the medical scene in early China. Yet from the first millennium bce

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there are moral exempla of tyrants dissecting the bodies of officials and pregnant women, of the careful weighing and measurement of the viscera of an executed rebel leader (Wang Mang 王莽 r. 9–23), and records of the results of such cadaver dissections in the canonical medical works.13 In the second century, Hua Tuo 華佗 famously performed abdominal surgery with the aid of an anaesthetic called mafeisan 麻沸散, which apparently rendered his patients insensible as though drunk.14 Chinese theorists were not indifferent to the physical body. However, they viewed it first and foremost as a dynamic system of functions and relationships, governed by the same regularities observable in the external world. The body was not a discrete object to be considered in isolation but a piece of a correlative universe that echoed with sympathetic resonances and significant similarities. It was this that made the body susceptible to medical diagnosis and treatment. Interlocked theories of cosmogenesis and statecraft, structured around the polarity of yin 陰 and yang 陽 and the wuxing 五行 ‘Five Agents’, provided the framework for sets of correspondences that, by the third century bce, had started to dominate ritual and technical thinking. For instance, Lüshi chunqiu argues that the emperor’s conduct, diet, vestments, and place of residence must be aligned with a ritual schedule based on astronomically calculated calendrical divisions.15 Around the dawn of empire they also organized classical Chinese medical thought, sometimes known as the Medicine of Systematic Correspondence.16 Yin and yang are not substances or fixed properties, and are most satisfactorily described as relational categories that organize the wanwu ‘myriad things’ in ‘complementary opposition’. Expressed most fundamentally in spatial alternation, such as back/front and inner/outer or in temporal contrasts such as day/ night or the alternation between warm and cold seasons in the yearly cycle, yin and yang were to become key criteria for classifying physical substances and describing physiological and pathological processes and, thus, all the vicissitudes of health and sickness as well as stages in the development of diseases. The Five Agents schema extended the correlative basis for understanding the body by means of interrelated series of five: five seasons (spring, summer, late summer, autumn, and winter), five sapors, five viscera, and so on. It offered an overarching template for relations between the world and the human body, rooted in a fivefold division of the year. The sets of correspondences summarized here model the natural (that is proper and salutary) relationship of the body with its surroundings, and the structure and form of what Joseph Needham called the ‘organismic’ universe.17 The image of the microcosmic body was further strengthened by social and political analogy. This is particularly obvious in the yin and yang correlations of the Yellow Emperor’s Four Canons, that is noble/ lowly and controlling/being controlled. Whereas the treatises compiled into the Yellow Emperor’s inner corpus do not bear witness to their authors, the late Han period saw the publication of a number of medical texts that speak to us in a more individual voice. In particular, the work of the scholarphysician Zhang Zhongjing 張仲景 (c.mid-second to third century) had a decisive influence on the later course of Chinese medical theory. A foreword to the received text, attributed to Zhang himself, relates that he published two monographs on

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febrile disease in response to an epidemic that devastated his town. These two treatises were subsequently combined to form the much-cited Shang Han Lun 傷寒論 (Treatise on Cold Damage), which describes the course of febrile disease and includes a compendious materia medica with medicines for each stage. The ‘cold damage’ of the title is a systematic aetiological theory of febrile disease due to external attack in light of the progress of yin and yang. Eight centuries later, during the Song Dynasty (960–1279), Zhang’s magnum opus gained a fresh lease of life when it was identified by government officials desperately searching for sources of ancient wisdom to combat a deadly series of epidemics.18 They prepared a new edition, which is still published and consulted today, and enjoys particular popularity in Japan.

Religion and medicine Society in early China was peopled by religious figures who mediated spirit presences, including gods, nature spirits, and deceased ancestors. The wu 巫—diviners, mediums, shamans, or specialists in ritual, both male and female—were employed at court to avert demonic influences, resolve inauspicious events, and perform the work of communicating with the invisible realm. As an integral part of exorcisms and sacrifices to the spirits of nature at the correct times in the annual and seasonal cycle and summoning up the spirits of the departed at funeral ceremonies, they issued proclamations to expel illness and its causes, and used effigies and talismans to intervene in the course of disease. Female wu performed ritual songs, dances, and prayers, and participated in healing ceremonies alongside priests and medical practitioners of various kinds.19 The religious arena provided crucial continuity in face of dynastic rupture and political transformation. In medieval times, certain medical ideas were able to thrive and evolve in the context of religious movements.20 At the beginning of the first century ce, millennial cults sprang up across China, some of them posing a threat to the power of the state, like the Yellow Turbans sect of Zhang Jue or Zhang Jiao (張角, d.184), which led an uprising against the Han ruling house. Though the uprising was crushed, it signified the beginning of the end for the Han empire, which collapsed in 220 amid local wars, famine, epidemics, and waves of refugees. One of the ways in which the Yellow Turbans won converts for their cause was by offering to heal the sick, often by such ancient practices as incantation, and burning talismans and administering the ashes in water. Their main sacred text was the Taiping Jing 太平經 (Canon or Scripture of Heavenly Peace), a text grounded, on the one hand, in the theory of the Unity of Heaven and Humanity (天人合一), wherein individual virtue was thought to invite corresponding response from Heaven. On the other hand, it also contained theoretical descriptions of the body comparable to those found in Huangdi neijing, as well as numerous longevity prescriptions encompassing meditation, breath and qi techniques, self-cultivation, diet, plant and animal drugs, and the use of charms and talismans. It was later assimilated into the Daoist canon.21

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The Way of the Celestial Masters (Tianshi Dao 天師道), which also originated in this period, marked the beginning of Daoism as an organized religion. Religious Daoism found many adherents among the medieval ruling classes. The Celestial Masters held that illness was a punishment for evil deeds and could be cured by confession, submitting petitions in due form to the Celestial Bureaucracy, and atonement through acts of benevolence and public charity such as building roads and donating food to the poor.22 The Shangqing 上清 (Highest Clarity) school of Daoism, which grew out of the same tradition, was in part a reaction to the southward migration of the Celestial Masters, interfering with local religious structures. The Shangqing school rose to prominence in the fifth century under the guidance of Tao Hongjing 陶弘景 (456–536). A key figure in the history of alchemy and medicine as well as religious Daoism, he not only compiled the Shangqing corpus, but also wrote treatises on alchemy and published the first known critical edition of the Shennong pharmaceutical canon. He enjoyed imperial favour and patronage, especially for his work in the field of alchemy.23 The conjunction of medicine, alchemy, and high office is a recurrent theme in the lives of prominent medieval authors.24 A distinguished example is the scholar-physician Sun Simiao 孫思邈 (581–681/2 ce), who held government posts at the beginning of the Tang period. Sun Simiao was noted for his eclectic intellectual and religious views, which are exemplified in two massive and wide-ranging medical works where Buddhist chants and demonic medicine stand on an equal footing with classical scholarly medicine.25 Like Tao Hongjing, Sun Simiao was a seminal figure in the development of alchemy. Classic Chinese alchemy set out to understand and master the workings of the cosmos by studying its physical nature. By scrutinizing a substance in all its stages of transformation from its primordial state, an alchemist could learn to apply powerful analogies with cosmic time cycles—from the dawn of time to its end, wherein lies its beginning. Through a carefully calibrated process of successive heating and cooling, the alchemists attempted to speed up the sequences of time so as to transmute imperfect base metal into perfected ‘gold’. These practices were known as waidan 外丹 (external alchemy). The alchemists’ desire to master the physical world led them on a quest for elixirs of longevity and immortality. Highly toxic minerals like cinnabar, mercury, lead, and arsenic were used to preserve the material body in life as well as death. Arsenic, a commonly used ‘mineral drug’, is a nerve poison: when consumed over an extended period, even in small quantities, it results in lapses of consciousness, weakness, cardiac abnormalities, peripheral neuropathy, diarrhoea, and delusions. However, it may also induce hallucinations and ecstatic visions; and it seems that this, together with the gradual character of the pathology, allowed users to embrace the symptoms of poisoning as acceptable side-effects. Countless Chinese literati and even some of the emperors of the Tang dynasty are said to have perished from the effects of immortality elixirs over the centuries and this tragic irony brought about the demise of external alchemy.26 As commercial and cultural interchange between China and the outside world intensified in the first century ce, Buddhism began to spread into China along the Silk Roads. Early Buddhism was at times misinterpreted (sometimes deliberately) in China as a Daoist sect and much of Buddhist terminology, thought, and symbols were adopted by

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Daoist sects.27 Buddhism offered a radical new view of the afterlife centred on the idea of progressive incarnations of an immortal personal soul, and it proposed meditation and prayer as the main path to salvation and healing. The Buddhist devotion to deities struck a particular chord with indigenous popular religion and the Buddha was readily assimilated into the local pantheon, often in the role of Medicine King, as were the boddhisatvas of healing, undergoing thorough sinicization in the process. Both Buddhism and Daoism prospered greatly in the Sui (581–618) and Tang (618– 907) period, when China was unified once more after centuries of division. The Sui emperors especially were active patrons of Buddhist institutions. At its apogee in the early Tang, Buddhism was the main form of religious observance across the entire social spectrum. Under the auspices of the Tang ruling house (the Li family), debates among exponents of the major religious traditions were staged at Court, creating a lively, competitive intellectual environment conducive to the fusion of religious ideas and the exchange of healing practices.28 With increasing prosperity, Buddhist monasteries became important cultural and social centres, some of them providing cheap hostel accommodation, epidemic relief, or free in-patient care in infirmaries called Beitian fang 悲田坊 (fields of compassion).29 As ever, healing proved to be an effective mode of evangelism. However, the increasing material wealth and influence of monastic institutions brought them into collision with the state. Literary depictions of monk and nun healers play upon stereotypes of debauchery and immorality, much as in medieval Europe and India. Monks specializing in the treatment of women’s illnesses bore the brunt of these prejudices. In the great suppression of Buddhism under the Tang emperor Wuzong from 842 to 845, thousands of monasteries were closed down or destroyed, their accumulated wealth was seized, and their infirmaries were taken over by the imperial authority.30 But despite this persecution, monastic centres continued to play a vital role in the preservation and scribal transmission of medical literature. Our current knowledge of Chinese medicine in the Middle Ages is derived in great part from manuscripts copied by Buddhist monks living in farflung communities along the Silk Roads.31

The Song period and politics Medicine received strong state support in the Northern Song dynasty (960–1127), owing to the personal involvement and interest of successive emperors, coupled with pressure on the Song government to tackle a series of major epidemics. The Song government sponsored the publication of medical texts, founded the first Imperial Medical School, and established a formal system of medical education. It launched an empire-wide initiative to collect and record local herbs and remedies, which greatly expanded the repertoire of materia medica. This in turn stimulated the production of new illustrated herbals and prompted a reappraisal of drug classifications. Seeking ways to combat the epidemics, theorists and practitioners revisited ancient medical learning and reintegrated it into

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current practice. In this climate, a new elite of scholarly physicians, the ru yi 儒醫 (literally ‘Confucian physicians’), emerged.32 Towards the end of the first millennium, in the period spanning the close of the Tang dynasty and the beginning of the Song, the empire entered a period of rapid and continuous economic change. With population growth and greater prosperity came a general expansion of the educated classes. As a consequence, competition for posts in the imperial bureaucracy—the traditional career destination for the educated elite—grew ever more fierce. A career in medicine came to be seen as an increasingly attractive alternative. From the outset, the Northern (early) Song Dynasty (960–1125) was marked by intense political debate focusing on the role of government and the appropriate extent of state intervention. This reached a crescendo in the late eleventh century, when the reforming statesman Wang Anshi 王安石 (1021–86) introduced a radical package of ‘new policies’ designed to modernize finance, agriculture, and administration. In this interventionist climate, the Bureau for the Editing of Medical Texts was established in 1057 to identify and publish an official canon of medical literature. This yielded thirty editions of canonical medical and pharmaceutical treatises and remedy collections and essentially shaped the corpus of early medical literature as we know it today. The rediscovery and promotion of the Treatise on Cold Damage of Zhang Zhongjing (second century) belongs to this period. A combination of factors at work from the twelfth to the fourteenth centuries (during the Song and Jin (1127–1235) and Yuan (1279–1368) dynasties) had far-reaching repercussions for the production of knowledge, especially in the area of medicine. Advances in printing technology enabled the official canons to be widely disseminated and also meant that medical knowledge could be accessed and transmitted outside closed medical lineages. The scale of the medical bureaucracy and of state involvement in medical training during these two centuries was unparalleled before or since, until the twentieth century at least. Some officials had medical texts inscribed or displayed in public places as a public information service and as a way of enhancing the government’s image. One official took it upon himself to demonstrate the efficacy of medicines by having them forcibly administered to the people of the district.33 The Southern Song (1125–1275) government made real efforts to address public health issues, commissioning elite doctors to dispense drugs as epidemic relief, but uptake in the southern regions was poor. Officials reported that the populace shunned and isolated the sick, or entrusted them to the care of wu, traditional practitioners specializing in religious healing.34 Some officials responded by punishing spirit healers, smashing their altars, giving them official medical texts to study, and requiring them to renounce their old occupation and become farmers or medical practitioners. Urbanization and the growing market economy favoured the development of knowledge networks, and provided the rising elite of scholarly physicians with unique opportunities to engage in the production of texts and innovative forms of medical activity. After the abolition of civil service examinations under the Yuan (Mongol) dynasty (1279–1368), publishing medical texts became a key way for a scholar and gentleman to

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exhibit his intellectual and social status while also ‘accumulating virtue’—a meritorious activity with both private and public aspects, and both moral and practical advantages.

Intersections From the late Han period onward, and probably far earlier (although the scarcity of evidence makes this more problematic), the history of medicine and healing in China needs to be viewed in a larger geographical context that extends eastward into what is now Korea and, in the Middle Ages, beyond that to Japan, and westward and southward to Mongolia, Tibet, India, and all the nations and cultures that lie along the overland routes linking the ancient capitals with Persia and the lands further west. The medieval manuscripts recovered in the library cave at the Dunhuang shrines in today’s Gansu province, north-west China, offer a rich mine of source material to investigate the connections and tensions between periphery and centre, or rather between multiple peripheries and centres. Recent research into these sources, most of which are held at the British Library and the Bibliothèque Nationale de France, shows the remarkable degree of penetration of the official medical texts generated in the capital, but it also reveals an enthralling range of local medical material and international influences that have left little trace in the official canons and other transmitted literature.35 Far away from the Chinese borders, at the end of one of the Silk Routes in Mongolian Ilkhanid Persia, scholars and translators from China, Tibet, Kashmir, India, Europe, and Arabia congregated, around the turn of the thirteenth and fourteenth centuries, at the court of the Judeo-Muslim scholar and Vizier Rashid al-Din (1274–1318)—one of the great intellectual melting pots of its time. Himself a court physician, Rashid al-Din sponsored medical translations and produced a monumental collection of medical knowledge edited and collated from a vast range of sources including Chinese sources. This literature is only now being studied in light of its significance for cross-cultural transmission.36 In the end, however, one is left questioning how much influence scholarly translations like these can have had on actual medical practice. A more accessible point of entry into the practical business of transmitting knowledge may be provided by translating and analysing books of remedies and recipes. In translating concrete details and practices, the present-day translator is brought up against some of the same problems of identifying and interpreting substances and techniques that must have challenged earlier translators, merchants, and ordinary end-users. The Yinshan zhengyao 飲膳正要 evokes a vision of Mongolian expansion that is very different from the popular clichés of rape and pillage.37 Viewing the Mongolian imperial presence through the sensual, subtle medium of ingredients and spices, and the technology and philosophy of cookery and diet, we see how it functioned as a vehicle for cultural dissemination and assimilation throughout thirteenth- and fourteenth-century Asia. Yinshan zhengyao incorporates and interprets dietary and technical knowledge from Muslim and Arabic areas, often sinicizing it in

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the process. Buell’s ongoing work is an English translation of Huihui yaofang (Muslim pharmaceutical prescriptions), a Chinese text dating to the Mongolian Yuan dynasty that includes many Arabic prescriptions, with Arabic and Persian drug names noted after the Chinese equivalents. It provides a fascinating window on the network of commercial, religious, and ethnic interchange that formed Chinese medical culture in and after the period of the Mongol emperors. The reception of new medical technologies from abroad was played out against the background of an empire in crisis, under attack from the imperialist powers of Europe, Japan, and America. As the increasingly fragile Qing dynasty lost its grip on central power, new medical techniques were entering the country, mainly through Christian missions. The first Treaty of Tianjin (1858), which granted foreigners immunity from Chinese laws and the freedom to travel, enabled foreign missionaries, for the first time, to acquire property and to live outside the treaty ports. By the 1890s, missionary clinics had been set up in large towns and cities in many parts of the country, and it was commonly acknowledged that free medical care could win converts where preaching failed. Missionary medicine appealed directly to the poor; wealthier people, who had the alternative of paying for expert medical care, were apt to despise missionary medicine and to be suspicious of its religious and political agenda.38 From the early eighteenth century, European anatomical texts had been available in China in Jesuit translations but, as long as they were not backed up by verifiable methods of treatment, they were regarded as little more than an exotic intellectual curiosity.39 This changed in the middle of the nineteenth century, with the advent of impressive new foreign techniques, mostly surgical and anaesthetic.40 However, spectacular though some of these were (including cataract surgery and the removal of tumours, cysts, and stones), they tended by their nature to align Western surgeons not with learned scholarphysicians, but with humbler medical artisans. Since antiquity, many kinds of petty and skin-deep surgery had been routinely carried out in China, including bloodletting, lancing abscesses, suturing wounds, removing projectiles, repairing hernias, surgical treatments of haemorrhoids, castration, and acupuncture.41 A small number of foreign miracle drugs, notably chloroform and quinine, were added to the repertoire of materia medica. Smallpox prevention provided an arena for the negotiation of indigenous and foreign technologies. Since the end of the first millennium, symptoms identifiable retrospectively as smallpox are known to have been endemic among young children. These symptoms were classified under the rubric of ‘cold damage’, the syndrome pattern used since the Han period to explain feverish diseases and other, frequently infectious, conditions deemed to be caused by external pathogens. However, in the 1500s, medical practitioners in southern China had begun to carry out variolation (introducing infected matter from a patient with smallpox into the body of a healthy child so as to achieve immunity). There were five types of variolation, with accompanying rituals, intended to remove ‘foetal poisoning’—according to Chinese medical theory, a hereditary disease arising partly from a disorderly lifestyle, and sexual, emotional, or dietary excess, and thus an oblique moral indictment of the sufferer’s mother.42

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Variolation did indeed prove effective. Thus when Jenner’s vaccine was first introduced into China in 1805 by Dr. Alexander Pearson, it was cast as the competitor of variolation, creating tension and conflict particularly in rural areas. While variolation was carried out privately, Jennerian vaccination was offered free of charge by some Chinese charitable organizations; however, the vaccine was difficult to obtain, preserve, and distribute. Compared with variolation, vaccination had a firmer methodological basis and better safety record, was easier to deliver, and did not carry the risk of spreading smallpox, making it suitable for institutional mass provision. Nonetheless, each side claimed that their own technique involved less human suffering and left fewer disfiguring pockmarks, and variolation continued to be practised into the twentieth century.43 Within the Qing (Manchu) administration, the cause of technological Westernization was espoused by a hard core of ethnic Chinese officials who especially favoured the adoption of foreign military technology. These fundamentally conservative reformers established the Self-Strengthening Movement (1860–95) under the slogan ‘Chinese learning for our foundation, Western learning for practical application’.44 There followed a limited programme of industrialization, which gave rise to the Fuzhou dockyard and Jiangnan arsenal in Shanghai. In a similar spirit, the Tianjin Medical School was founded in 1881 as the first state institute for training in ‘Western medicine’.45 The urgency of reform was underlined by China’s defeat in the Sino-Japanese war of 1894–5 and the debacle of the Boxer Uprising, which further strengthened the hold of the imperialist powers over the ailing Qing state.46 Opinion in China was polarized: while conservative Qing officials repudiated any form of institutional modernization, many of their reformist opponents saw wholesale Westernization as the only way forward. Numerous Chinese intellectuals went abroad to pursue studies in medicine or natural science, particularly in Japan, which had instituted a thorough-going top-down programme of reform after the 1868 Meiji Restoration. Medical training abroad is a common theme in the lives of the major Chinese revolutionary writers and reforming politicians of the early twentieth century.47

Reading the body culturally: sense and sensuality China’s most notable contribution to the mapping of the human body may lie not so much in the visual representation of its functionality as in descriptions of the sensory apprehension of the inner body. In his work on the cultural and social history of perception, Shigehisa Kuriyama explores the contrasting perceptual modalities whereby European and Chinese images of the body were constituted, and describes how different ways of understanding the body privilege distinct ways of seeing. For example, Chinese complexion diagnosis, a form of faciomancy that identifies bodily imbalances in the aura or colours of the face, is grounded in botanical metaphors deeply embedded in

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early Chinese language and culture. Like the flower of a plant, the complexion is a visible outward manifestation of the underlying health and strength of the human organism. Beyond the modern hegemony of the outward eye, Kuriyama finds differences between knowledge derived from touch (haptic knowledge) in the Chinese and European traditions. He contrasts the knowledge of the pulse derived from ancient Greek tradition with the Chinese palpation of the mai 脈—a term in which ideas about bodily channels merge with the sensory awareness of the rhythmic pulsation of the vessels—illustrating how direct experience of the body is inseparable from culture-bound preconceptions and theoretical constructs.48 The social historian’s desire to encompass human experience in its broadest sense has led a growing body of scholars to a new methodological turn, known as ‘sensory history’, that challenges the presumption that ‘the past is best seen rather than, say, heard or smelled’.49 By exploring culturally specific styles of perception, this approach holds out the possibility of making histories that are situated within the sensibilities of their subjects. It has produced intriguing and richly evocative histories alive with sounds, tastes, and smells. China has a great deal to offer this methodological turn in terms of both sources and perspectives.50 In documenting the felt, internal experience of being well, fit, and strong, and the sensations of pain, pleasure, and passion, the Chinese healing arts also medicalized the world of the senses.51 Out of this culture of attending to the life of the inner body, and the language and theories that it generated, emerged the single most crucial innovation in early Chinese medicine—the concept of qi. The semantic circuits summoned up by qi confound any simple distinction between mind, body, and emotions, uniting them as changing states of the experienced self.52 The persistence of the concept of qi evokes the aesthetics of a time when the boundaries between these ways of experiencing the self and the world were not clear-cut.53 Inner body qi cultivation has always had political resonances. Scholars studying contemporary manifestations of self-cultivation often point to the use of the body as a locus of resistance to authority or the state. Undoubtedly, some forms of qi cultivation, and allied religious and medical rituals, have functioned as expressions of political and personal autonomy. This can be seen in the bodily cultivation practices of hermits and political recusants from pre-imperial times onwards and of the early revolutionary armies, as well as the purportedly passive protests of the Falun Gong 法輪工, which have recently aroused such concern in the Chinese authorities.54 Equally, working with inner body qi can be a deeply conservative and conformist practice. ‘Studies of culture need to pay at least as much attention to sites of concentrated cultural practice as to the dispersed sites of resistance.’55 Traditionally, selfcultivation forms part of the culture of artistic expression and refined leisure expected of retired government officials, living out their remaining years in tranquil rural seclusion. Today’s bands of post-menopausal, sword-wielding women practising their taijiquan in Chinese municipal parks are no more likely to endanger the status quo.

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Conclusion Most of the researchers cited in this chapter have, in one way or another, challenged the premise that we can valuably look back at historical events from the perspectives of our current concerns. Certainly those histories that seek to understand sources as they were understood in their own time are more likely to provide rich sociocultural contexts and so capture the historical moment. For the ancient worlds this has meant that recent histories are more intent upon the ritual and religious worlds within which classical medical ideas formed and flourished. For China, what earlier historians left out was, for example, the pervasive power of calculating auspicious times and places, the plurality of beliefs attendant on any medical encounter, and accounts of healing in religious organizations. Yet, it is a folly to think that we can entirely extract the concerns that shape us as readers and writers in our own time from our historical narratives. Nor should we. Both authors of this chapter are as much practitioners of modern qi gong, martial arts, and Chinese medicine as we are historians. Our readings of primary text and interpretation of sources consciously lean towards practice-orientated accounts, as textured through our own experience. Such historical enterprise dignifies itself with the idea that it is possible to share something of the sensory and perceptive style of the originators of early Chinese healing practices, and that doing so is germane, indeed essential, to deepening our appreciation of their textual legacies. Added to textual filiation and institutional histories, body-centred readings enable one to observe more readily the fluid interplay between exercise, diet, pharmacology, cuisine, ritual, and cosmography, in the constitution of Chinese healing practice. With these methodological tools at our disposal, the door also opens into a rich interregional cultural and material history, and a narrative not only concerned with internal ‘Chinese’ genealogical developments but also ready to tackle the transitions, transformations, and transmissions that happen to medical knowledge as it is exchanged between different peoples across physical domains as well as down through generations of healers.

Notes 1. David N. Keightley, ‘Shamanism, Death, and the Ancestors: Religious Mediation in Neolithic and Shang China (ca. 5000–1000 b.c.)’, Asiatische Studien/Études Asiatiques 52 (1998), 763–828. 2. Donald Harper, Early Chinese Medical Literature: The Mawangdui Medical Manuscripts (London/New York: Kegan Paul, 1998). 3. Anthony Christie, Chinese Mythology (London: Hamlyn, 1968), 84–91. 4. Martin Palmer, T’ung shu, the Ancient Chinese Almanac, 1st edn (Boston: Shambhala, 1986); Roel Stercx, ‘Religious Practices in the Han Dynasty’, in Michael Loewe and Michael Nylan (eds), China’s Early Empires, a Re-Appraisal (Cambridge: Cambridge University

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5. 6. 7.

8. 9. 10. 11. 12. 13.

14. 15.

16. 17. 18. 19.

20.

21. 22.

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Press, 2010); Michael Nylan, ‘Yin-yang, Five Phases and Qi’, ibid. 398–414; Vivienne Lo, ‘Huangdi Hama jing (Yellow Emperor’s Toad Canon)’, Asia Major 14 (2001), 61–99. Nathan Sivin, ‘Huang ti nei ching 黃帝內經’, in Michael Loewe (ed.), Early Chinese Texts: A Bibliographical Guide (Berkeley: Society for the Study of Early China, 1993), 196–215. Paul U. Unschuld, Medicine in China: A History of Ideas: Comparative Studies of Health Systems and Medical Care (Berkeley: University of California Press, 1985), 263–95. Suwen 3.8. The Suwen is part of the Inner Canon of the Yellow Emperor. For a study of the Suwen see Paul U. Unschuld, Huang di nei jing su wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text (Berkeley/Los Angeles: University of California Press, 2003). Lingshu 12. See Wu Jing-Nuan, Ling shu or The Spiritual Pivot (Honolulu: University of Hawaii Press, 1993), 69. Huangdi neijing taisu 黃帝內 太经素 5; Lingshu 4.15 ‘Wushi ying’ 五十營, in Wu JingNuan, Spiritual Pivot, 83. Vivienne Lo, ‘Spirit of Stone: Technical Considerations in the Treatment of the Jade Body’, Bulletin of the School of Oriental and African Studies 65 (2002), 99–128. Wu Jing-Nuan, Spiritual Pivot, 258–63. Bridie Jane Andrews, ‘The Making of Modern Chinese Medicine, 1895–1937’, doctoral thesis, University of Cambridge, 1996, 20–48. John Knoblock and Jeffrey Riegel, The Annals of Lü Buwei (Stanford: Stanford University Press, 2000), 596; Louis Fu, ‘A Forgotten Reformer of Anatomy in China: Wang Ch’ing-Jen’, ANZ Journal of Surgery 78 (2008), 1052–8; Lingshu 12, ‘Channels and Rivers’ 經水. See Wu Jing-Nuan, Spiritual Pivot, 69, or Fu, ‘A Forgotten Reformer of Anatomy’, 1052. Zheng Bocheng, ‘The Miracle-Working Doctor’, Journal of Traditional Chinese Medicine 5 (1985), 311–12. Lingshu 11.77. See Wu Jing-Nuan, Spiritual Pivot, 254–67; Shigehisa Kuriyama, The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine (New York: Zone Books, 1999), 244–5; Sun Xiaochun and Jacob Kistemaker, The Chinese Sky during the Han: Constellating Stars and Society (Leiden/New York: Brill, 1997), 96–7. Unschuld, Medicine in China, 51–92. Joseph Needham and Ling Wang, Science and Civilisation in China, Vol. 2: History of Scientific Thought (Cambridge: Cambridge University Press, 1956), 291–2. Asaf Moshe Goldschmidt, The Evolution of Chinese Medicine: Song Dynasty, 960–1200 (London: Routledge, 2009), 69–102. Lothar von Falkenhausen, ‘Reflections on the Political Role of Spirit Mediums in Early China: The Wu Officials in the Zhouli’, Early China 20 (1995), 279–300; Michael J. Puett, To Become a God: Cosmology, Sacrifice, and Self-divinization in Early China (Cambridge, MA: Harvard University Press, 2002); Harper, Early Chinese Medical Literature, 148–83; and Unschuld, Medicine in China, 17–50. Unschuld, Medicine in China, 117–53; Sakade Yoshinobu 坂出祥伸, Taoism, Medicine and Qi in China and Japan (Osaka: Kansai University Press, 2007); Ute Engelhardt, ‘Qi for Life: Longevity in the Tang’, in Livia Kohn and Yoshinobu Sakade (eds), Taoist Meditation and Longevity Techniques (Ann Arbor: Center for Chinese Studies University of Michigan, 1989), 263–96. Barbara Hendrischke, The Scripture on Great Peace: The Taiping jing and the Beginnings of Daoism (Berkeley: University of California Press, 2006). Peter S. Nickerson, ‘The Great Petition for Sepulchral Plaints’, in Stephen R. Bokenkamp (ed.), Early Daoist Scriptures (Berkeley: University of California Press, 1997), 230–60;

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23.

24. 25.

26.

27.

28. 29. 30. 31. 32. 33. 34. 35.

36.

37.

38.

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Terry F. Kleeman, ‘Licentious Cults and Bloody Victuals: Sacrifice, Reciprocity, and Violence in Traditional China’, Asia Major, 3rd series, 7 (1994), 185–211. Michel Strickmann, ‘The Alchemy of T’ao Hung-ching’, in Holmes Welch and Anna K. Seidel (eds), Facets of Taoism: Essays in Chinese Religion (New Haven, CT: Yale University Press, 1979), 123–92; Michel Strickmann and Bernard Faure, Chinese Magical Medicine (Stanford: Stanford University Press, 2002). Strickmann, ‘Alchemy’; Strickmann and Faure, Chinese Magical Medicine; Nathan Sivin, Chinese Alchemy: Preliminary Studies (Cambridge, MA: Harvard University Press, 1968). Sivin, Chinese Alchemy; Sabine Wilms, ‘The Female Body in Medieval China : A Translation and Interpretation of the “Women’s Recipes” in Sun Simiao’s Beiji quanjin yaofang’, doctoral dissertation, University of Arizona, 2002; Elena Valussi, ‘The Chapter on “Nourishing Inner Nature” in Sun Simiao’s Qianjin yaofang’, MA thesis, School of Oriental and African Studies, 1996; Fang Ling, ‘La tradition sacrée de la Médecine Chinoise ancienne. Étude sur le Livre des exorcismes de Sun Simiao (581–682)’, doctoral dissertation, Ecole Pratique des Hautes Etudes, 2001, x. Joseph Needham, ‘Elixir Poisoning’, in Clerks and Craftsmen in China and the West: Lectures and Addresses on the History of Science and Technology (London: Cambridge University Press, 1970), 316–39. Erik Zürcher, The Buddhist Conquest of China; The Spread and Adaptation of Buddhism in Early Medieval China (Leiden: Brill, 1959); Stephen R. Bokenkamp, ‘Daoism: An Overview’, in Lindsay Jones (ed.), Encyclopedia of Religion (Detroit: Macmillan Reference USA, 2005), 2176–92. Christine Mollier, Buddhism and Taoism Face to Face: Scripture, Ritual, and Iconographic Exchange in Medieval China (Honolulu: University of Hawai’i Press, 2008). Charles D. Benn, Daily Life in Traditional China: The Tang Dynasty, ‘Daily Life through History’ series (Westport, CT: Greenwood Press, 2002), 227. Stanley Weinstein, Buddhism under the T’ang (Cambridge/New York: Cambridge University Press, 1987); Needham, Clerks and Craftsmen in China and the West, 277–8. Vivienne Lo and Christopher Cullen (eds), Medieval Chinese Medicine, trans. Penelope Barrett (London/New York: Routledge Curzon, 2005). Goldschmidt, The Evolution of Chinese Medicine, 103–46; Unschuld, Medicine in China, 154–88. T. J. Hinrichs, ‘The Medical Transforming of Governance and Southern Customs in Song Dynasty China (960–1279 c.e.)’, PhD dissertation, Harvard University, 2003, 33–4. Ibid. 31. Lo and Cullen (eds), Medieval Chinese Medicine; Vivienne Lo, ‘Acuponcture et Moxibustion’, in C. Despeux (ed.), Médecine, religion et société dans la Chine mediévale: Etude de manuscrits chinois de Dunhuang et de Turfan (Paris: L’Institut des Hautes Etudes Chinoises, College de France, 2010). V. Lo and Wang Yidan, ‘Blood or Qi Circulation? On the Nature of Authority in Rashīd al-Dīn’s Tānksūqnāma [The Treasure Book of Ilqān on Chinese Science and Techniques]’, in Anna Akasoy, Charles Burnett, and Ronit Yoeli-Tlalim (eds), Rashid al-Din as an Agent and Mediator of Cultural Exchanges in Ilkhanid Iran (London: Warburg Institute, 2011). Paul D. Buell, Eugene N. Anderson, and Charles Perry, A Soup for the Qan: Chinese Dietary Medicine of the Mongol Era as Seen in Hu Szu-Hui’s Yin-Shan Cheng-Yao (London/New York: Kegan Paul, 2000). Paul Cohen, ‘Christian Missions and Their Impact to 1900’, in Denis Twitchett and John King Fairbank (eds), The Cambridge History of China, Vol.10: Late Ch’ing, 1800–1911, Part

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40. 41. 42.

43.

44.

45. 46. 47. 48. 49. 50.

51.

52.

53. 54. 55.

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1 (Cambridge: Cambridge University Press, 1978), 543–90; W. G. Lennox, ‘A Self-Survey by Mission Hospitals in China’, Chinese Medical Journal 46 (1932), 484–534. Daniel Asen, ‘Manchu Anatomy: Anatomical Knowledge and the Jesuits in Seventeenthand Eighteenth-Century China’, Social History of Medicine 22 (2009), 23–44; Marta Hansen, Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China (London: Routledge, forthcoming). Andrews, ‘The Making of Modern Chinese Medicine’, 55–9. Adrian Le Tellier, La Chine: essai ethnographique, médical et hygiènique (Paris: Baillière et fils, 1899), 45–52. ‘Inoculation’, in Joseph Needham, with Lu Gwei-Djen, Science and Civilisation in China, Vol. 6: Biology and Biological Technology, Part 6: Medicine, ed. Nathan Sivin (Cambridge: Cambridge University Press, 2000), 114–74. ‘Introduction of Jennerian Vaccination’, in Chi-Min Wang and Lien-teh Wu, History of Chinese Medicine: Being a Chronicle of Medical Happenings in China from Ancient Times to the Present Period (Tientsin: Tientsin Press, 1932), 271–301. Liu Kwang-Ching, ‘Self-strengthening: The Pursuit of Western Technology’, in Twitchett and Fairbank (eds), The Cambridge History of China, Vol. 10, 491–542; and Edward L. Shaughnessy, China: The Land of the Heavenly Dragon (London: Duncan Baird, 2000), 85–6. Wang and Wu, History of Chinese Medicine, 437–62. Philip A. Kuhn, ‘The Taiping Rebellion’, in Twitchett and Fairbank (eds), The Cambridge History of China, Vol. 10, 264–317. Andrews, ‘The Making Of Modern Chinese Medicine’, 149–76. Kuriyama, Expressiveness of the Body. Mark M. Smith. ‘Making Sense of Social History’, Journal of Social History, 37 (2003), 165–86. Alain Corbin, The Foul and the Fragrant: Odor and the French Social Imagination (Cambridge, MA: Harvard University Press, 1986); Judith Farquhar, Appetites: Food and Sex in Postsocialist China. Body, Commodity, Text (Durham, NC: Duke University Press, 2002). Mawangdui Hanmu boshu, ed. by Organising workgroup, Vol. 4 (Beijing: Wenwu chubanshe, 1985); Shi wen 十問 30–32; Suwen 16; Unschuld, Huang di nei jing su wen; Vivienne Lo, ‘Tracking the Pain’, Sudhoffs Archiv 83 (1999), 191–211. Vivienne Lo, ‘Pleasure, Prohibition and Pain: Food and Medicine in China’, in Roel Sterckx (ed.), Of Tripod and Palate: Food, Politics, and Religion in Traditional China (New York/Basingstoke: Palgrave Macmillan, 2005), 163–65; Thomas Ots, ‘The Silenced Body—The Expressive Leib: On the Dialectic of Mind and Life in Chinese Cathartic Healing’, in Thomas J. Csordas (ed.), Embodiment and Experience: The Existential Ground of Culture and Self (New York: Cambridge University Press, 1994), 116–36. Robert Jütte, A History of the Senses: From Antiquity to Cyberspace, trans. James Lynn (Cambridge: Polity Press, 2005), 25–31. Nancy N. Chen, Breathing Spaces: Qigong, Psychiatry, and Healing in China, (New York/ Chichester: Columbia University Press, 2005), 369–74. W. H Sewell, ‘The Concept(s) of Culture’, in Victoria E. Bonnell, Lynn Hunt, and Richard Biernacki (eds), Beyond the Cultural Turn : New Directions in the Study of Society and Culture (Berkeley/London: University of California Press, 1999), 35–61, at 56.

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Select Bibliography Harper, Donald, Early Chinese Medical Literature: The Mawangdui Medical Manuscripts (London/New York: Kegan Paul, 1998). Hinrichs, T. J., ‘New Geographies of Chinese Medicine’, Osiris 13 (1998), 287–325. Kuriyama, Shigehisa, The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine (New York: Zone Books, 1999). Lo, Vivienne, and Christopher Cullen (eds), Medieval Chinese Medicine: The Dunhuang Medical Manuscripts (London: Routledge Curzon, 2005). Pregadio, Fabrizio, Great Clarity: Daoism and Alchemy in Early Medieval China (Stanford, CA: Stanford University Press, 2006). Unschuld, Paul U., Huang Di nei jing su wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text, with an Appendix: The Doctrine of the Five Periods and Six Qi in the Huang Di nei jing su wen (Berkeley: University of California Press, 2003). Zhan, Mei, Other-Worldly: Making Chinese Medicine Through Trans-national Frames (Durham, NC: Duke University Press, 2009).

chapter 10

m edici n e i n isl a m a n d isl a m ic m edici n e hormoz e brahimnejad

The term ‘Islamic medicine’ has appeared to many historians loaded with religious overtone, which they often found necessary to dispel by long warnings that it was not exclusively Islamic or Arabic, but included also works of non-Arab and non-Moslem scholars, such as Persians, Jews, Indians, or even Europeans.1 ‘Islamic medicine’ suggests a homogeneous system, regardless of the fact that such a term was never used either by laity or by physicians in Islamic countries before the nineteenth century, whereas ‘medicine in Islam’ contained a wide range of practices and theories from humoral to folk practice and faith and magic healing. For two reasons, however, we might call this medicine ‘Islamic’: firstly, because it was developed under the Islamic rulers’ patronage; and secondly, because it was part of the intellectual process of the formation of Islam itself by associating religion and science, illustrated in the curriculum of the madrasas (Islamic colleges). Medical histories produced since the nineteenth century have not delved into the intellectual and socio-political factors behind the choice of the term ‘Islamic’. The aim of this chapter is not to provide a history of ‘Islamic medicine’, but to examine the key developments that led to its formation, by addressing its theoretical, practical, and institutional features and the ways in which these features were formed and developed in relation to both pre-Islamic and Islamic resources. The dilemma created by a pre-Islamic and Islamic dichotomy was experienced and discussed by the Islamic scholars down to the modern period.2 Yet, the ‘superiority’ and distinction of Islam, as a new religion and rising political power, was to be asserted all the more because it borrowed from pagan cultures. It was this endeavour that eventually informed the development of medicine in Islam examined in this chapter.

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Medicine in early Islam Contemporary sources that could inform us about the state of medical knowledge and practice at the time of the prophet Mohammad (570–632) are extremely scant. The major reliable source would be the Koran itself but the Koran contains nothing about medicine other than advices such as ‘how the faithful should wash for prayer when they are sick,’ or ‘honey has curing effect,’ or ‘eat and drink but not to excess.’3 The sayings of the Prophet on the matter of health and medicine were transmitted orally through generations before being collected and published posthumously under the title of T. ibb al-nabi (Medicine of the Prophet), and thus it may not represent the unaltered form of Bedouin medicine during Mohammad’s time. Nevertheless, emphasis on invocation and the healing effect of prayers in Prophetic medicine is reminiscent of the supernatural healing methods in the Bedouin Arabia. Magic and supernatural healing were accompanied by physical treatments such as cupping, cautery, venesection, and bone-setting,4 practices that may have had local origin and were not necessarily borrowed from Greek medicine.5 In the Koran, jinn, as a supernatural spirit, as well as man, are created to pray to Allah.6 This concept of jinn is not unrelated to the jinn in contemporary popular culture, which can either cause illness or restore health.7 The animistic conception of illness, according to which diseases were considered as spiritual beings inhabiting humans, might find its roots in the idolatry that was widespread among tribes of the Arabian Peninsula.8 However, as in every other society, magic or faith healing was coupled or alternated with medical treatment, which in this case was predominantly based on everyday experience. Medicinal effects of herbs and foods were known and the same customs continued with Islam. In time, some of these items would carry religious connotations. The date, the staple food at the time of the Prophet, has become in some Islamic countries a sacred diet, and donating dates especially in religious festivals is said to be rewarded. Affinities between Islam, Judaism, and Christianity, illustrated in the terms and concepts common to the Koran and the Old and New Testaments, had parallels in the field of medicine. Arab populations were either within the remit of the two empires of Persia and Byzantium or in relation with them, whence some similarities in medical knowledge and practice emerged.9 The use of Greek terms in contemporary Arab poetry bears witness to the influence of Greek medicine there.10 This influence grew in the century following Islam’s conquering of regions belonging to the Byzantine and Persian empires. In the oral literature, one finds some anatomical knowledge of organs of the body, such as liver, heart, spleen, stomach, and bowels. The liver is the seat of hunger, thirst, and passion (including anger), the kidneys are the seat of greed, and the place of intellect is in the brain.11 The Prophet, advising that in the treatment of headache by cupping the cup should not be placed in the nape of the neck, followed this popular physiology, according to which the cerebellum is the site of memory.12

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Principles of Galenico-Islamic medicine Most Islamic medical tracts were meant to be comprehensive, dealing with pathology, aetiology, pharmacology, anatomy, rules for preservation or restoration of health, and so on. Al-Rāzi, or Rāzi (865–925), defines medicine as the ‘art of preserving the health, combating disease and restoring health to the sick’.13 Medicine, following the formulation of Ḥunayn ibn Ish.āq (809–73), is divided into theoretical and practical fields.14 According to Ibn Sinā, or Avicenna (980–1038), theoretical medicine, t.ibb nazari, meant learning about the ‘principles’ of medicine; for instance, fevers are of three categories, and temperaments are of nine types. Practical medicine, t.ibb ‘amali, consisted of methods of practice. ‘To treat hot inflammation, for instance, the practitioner should apply a drug that stops the inflammation growing, followed by a cooling drug before adding to these an emollient drug.’15 Sometimes practical medicine equates to ‘manual’ medicine. For Ibn Rid.wān (988–1061), practical medicine signified ‘the study of restoration of fractured bones, luxation, incision, stitches, cautery, perforation, ophthalmology and all other surgical procedures’.16 Usually, medical tracts discuss first general and theoretical principles of medicine, such as humours, fevers, symptoms, and anatomy, and then explore pharmacology and the prescription of drugs to prevent or cure diseases. The two main sources of Islamic pharmacology are Dioscorides’ On Medicinal Substance and Galen’s On the Powers of Simple Drugs. Dioscorides assigned to each substance (plant, mineral, and animal) attributes such as softening, warming, astringent, diuretic, and emetic. Galen fine-grained the quality of the drugs in four different degrees, from the weakest to the strongest, so that each drug was further qualified. Pepper is hotter than nard, because it is hot in the third degree while nard is hot in the second degree.17 Physicians were not always unanimous on the quality of drugs. In India, bannā’, for instance, was considered to be cold but Hakim Mohammad Sharif believed that ‘even the sour bannā’ is not devoid of hot quality, while sweet bannâ’, a drug that increases potency and strengthens the stomach, is hot in the second degree and dry in the third.18 In therapeutics, the appropriate degree of drugs’ qualities was used according to the state of health or the intensity of the malady. To cure an illness, Rāzi recommended diet in the first place; but if the illness was too complicated to be healed by diet, he prescribed simple or compound drugs according to the strength of the disease.19 According to Arzāni, Qarābādin is a Greek term that signifies a compound drug.20 Ibn Sinā, who devotes the fifth volume of his al-Qānun fi’l-T. ibb [Canon of Medicine] to this subject, attributes the necessity of compound drugs to the fact that usually diseases are complex and often develop from the combination of several pathological problems.21 The idea of humours circulating inside the body seems to be a projection of the image of observed liquids flowing out of the body (such as blood and pus). However, the theory of humour incorporating this universal concept belongs to Hippocrates, and in the form that is known today was elaborated by Galen (129–216).22 According to this theory, the human body is made of three parts: organs (a‘d. ā, plural of ‘ud. v), which are solid;

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humours (akhlāt, pl. of khilt.); and spirits, or pneumata (arvāh. , pl. of ruh.).23 There are four humours: blood (dam), black bile (sawdā), yellow bile (s·afrā), and phlegm (balgham). Each humour (khilt.) corresponds to two of the four primary qualities, which are also called mizāj (temperament)—mizâj literally meaning a mixture of different qualities: thus blood is hot and moist, black bile is cold and dry, yellow bile is hot and dry, and phlegm is cold and wet. If the quality and quantity of these humours (khilt. also means mixture) in the body are generally balanced, the person is healthy. An imbalance of humours causes illness, which can be cured when balance is restored. Not only man but also everything in the universe, including seasons, planets, plants, animals, and drugs, were associated with humoral theory. An inflammation caused by excess or putrefaction of blood should be treated by applying drugs of cold temperament.24 Each season, having specific temperament and quality (cold, humid, hot, or dry), can also cause illness or be useful for its treatment. The end of the autumn and the beginning of the winter is said to generate pestilences.25 Prognosis of the course of a disease depended on the phases and motion of the moon and ‘mineral, vegetal and animal products associated with the individual planets and zodiac signs were gathered at the astrologically favourable moments and were combined into drugs that were specific for diseases caused by the stars.’26

Greek science and Islamic medicine In the middle of the eleventh century in the city of Neishābur, in the eastern part of the Abbasid Caliphate, a renowned physician, ‘Abd al-Rahmān ibn Abi Sādeq-e Neishāburi (died after 1068), was surnamed Buqrāt-e Thāni (Hippocrates the Second). The use of such titles after the names of Greek physicians, frequent in Islamic history, demonstrates Greek intellectual influence in Islam. Although scholars differ in details, generally they support the idea that the assimilation of Greek science by Islam was the continuation of pre-Islamic Greek influence in the regions where Islam had expanded, a fact mainly due to the propagation of Hellenism in the aftermath of conquests by Alexander of Macedonia. Not only Eastern Christianity, represented by the Nestorians of Nisibis and Edessa, but also Zoroastrian religion was influenced by Hellenistic ideas, and particularly Aristotelianism.27 The main channel of Greek influence was, according to Montgomery Watt, the living tradition in different schools in Alexandria (Egypt), Gondishāpur (southwest of Iran), and Harrān (southeast of Turkey). However, this influence gained particular momentum with the transfer of the Alexandrian school, dominated by Aristotelian philosophy, first to Antioch in about 718, and a century later to Harrân and then to Baghdad, in the form of immigration of teachers and partly their library.28 According to Ullmann, the key factor in the transmission of Greek sciences into Islam is to be found in the Christianization of the south and east of the Mediterranean. With Christianity the Greek language was no longer the lingua franca and Greek sciences

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were translated into local languages, such as Syriac, Coptic, and Pahlavi, and with the advent of Islam, they needed to be translated into Arabic. At the same time, Christianization also changed the syllabus by eliminating poetry, tragedy, and historiography and keeping philosophy, medicine, and exact sciences. This trend, Ullmann states, was inherited particularly by Islam because Islamic theology encouraged the adoption of these sciences due to the fact that logic and dialectic helped give Islamic religion dogmatic basis.29 Dimitri Gutas, on the other hand, finds the origin of the integration of Greek sciences not in the continuation of the intellectual development under the aegis of the School of Edessa and the eastern Christian tradition, but in the transfer of a Sasanian imperial ideology to Islam, which encouraged the Abbasid caliphate to translate Greek sciences into Arabic.30 We should not, however, neglect religious opposition to the continuity of Greek culture. Conversion to Christianity in the Byzantine Empire led to the development of orthodoxy, which banned pagan Greek science. A similar phenomenon occurred in the Sasanian Empire. Consecutive with the centralization of power by Ardeshir-e Pâpakân and the reform of Zoroastrian religion by eliminating its pagan elements, the counsels of the Zoroastrian priesthood, who played an important role in the administration of the Empire, forbade all worship except the Zoroastrian faith and the ‘sword of Aristotle (as the polytheism and philosophy of the Greeks was called) was broken’.31 However, unlike the Byzantines, the Sasanids for political reasons accommodated the members of nonMagian religious groups. This strategy foreshadowed the way Moslems dealt with nonMoslem subjects.32 What made Greek science a favourite place and status in Islam, compared with the eclectic tendency of the Sasanian period, was the vital importance of Aristotelian theology for the elaboration of its dogma, via the Neo-Platonism borrowed from the Alexandrian School because its tenets were close to Koranic monotheism.33 The intellectual debates and political conflicts between the Mu‘tazilites and Ash‘arites, and finally the triumph of the traditionalists, such as al-Ghazzāli (1058–1111), who were opposed to philosophy but made use of it, bear witness to the new dynamics created by the expansion and formation of Islam as religion and political power. The inherent relationship between philosophy and medicine, embodied in the Arabic term hakīm (physician-philosopher) for physician, is based on Aristotelian natural philosophy (hikmat tabī ‘ī). The dilemma of ‘essence’ and ‘matter’, the order of their generations, their different qualities and temperaments, the composition of man from soul and body, the perennial character of the former and the decaying nature of the latter, and their link to the universe as conceived by Aristotle, gave a central place to medicine in the Islamic sciences. It is thus not surprising that medicine and astrology were, respectively, the first and second in importance in the translation movement. Hunayn ibn Ish. āq (809–73) claimed to have translated no less than 129 works, most of them Hippocratic texts as summarized by Galen, including the Aphorisms of Hippocrates (Fos. ul Buqrât). He also translated Aristotle’s Categories, Organon, and Physics, Euclid’s Elements, and Plato’s Republic. In general, Hunayn translated ninetyfive books of Galen into Syriac and thirty-nine into Arabic. Another seventy books were

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translated into Arabic and six into Syriac by his pupils.34 Many other translations were made from Greek sciences into Arabic before Hunayn. Thanks to this culture of translation, many books authored by Greek scholars and later lost in their original survived in Arabic versions. For instance, Galen’s On the Examination of the Doctor is not known in Greek, but there are two Arabic copies of this book in Alexandria and Bursa. Similarly, only four short passages of Galen’s commentary on Hippocrates About the Atmosphere have been preserved in Greek, quoted by Oribasius (320–400). However, in the ninth century, Ḥunayn translated this commentary into Syriac and his pupil Hubaysh translated the Syriac version into Arabic.35 Fragments of lost Greek works have also survived in Arabic translation, such as the collection of twenty-one clinical reports from Rufus.36 To these should be added other Arabic translations of Greek books no longer extant, but we know about them via their being quoted by later scholars. This is the case of Galen’s De demonstratione, used by Rāzi and Ibn Rushd (d. 1198 ce).37 The integration of Greek medicine by Islam was part of the process of the formation of Islam itself: ‘The Abbasid caliphs could not allow discord and differences between theologians and those interested in legal questions and brought pressure to bear on them to overcome their disagreement and form a common outlook.’38 In this sense, the development of science, including medicine, in Islam was tightly linked to the establishment of their power and the elaboration of Islam as a religion. This process influenced the way medicine in Islam was conceived and practised. All aspects of knowledge and techniques, which needed to be assimilated, received the blessing of religion. In an important number of tracts, often after the tenth century, an introductory passage refers to the sayings of the Prophet or the Koran to bless medical knowledge and justify its education. Al-‘ilm-‘ilmān: ‘ilm al-abdān wa ‘ilm al-adyān (‘Sciences are twofold: science of the body and science of religion’) is the most often quoted.39 Some authors even go as far as claiming that the science of the body (‘ilm al-abdān) is more important than the science of religion (‘ilm al-adyān), because without a healthy body the faithful cannot accurately perform their religion.

The format of Islamic medical literature The Greek literary format, adopted by Islamic scholars through translation, framed the development of medical knowledge in Islam and informed medical education. Most medical texts translated by Hunayn and his pupils consisted of commentaries and summaries for educational purposes. Hunayn perhaps followed the Alexandrian medical literature that mainly comprised the canon of sixteen books by Galen and the corresponding Summaria alexandrinorum (Alexandrian epitomes). No less than thirteen commentaries were written on the Canon of Avicenna. Often the authors claim that the purpose of their commentaries was to clarify obscure points or to correct erroneous ideas or interpretations in medicine. Be that as it may, commentary in the Islamic medical literature was a style and method of writing rather than a method for providing

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critical work. For example, the Shokuk ‘alā Jālinus (Doubts on Galen) of Rāzi, a criticism of Galen, was in turn criticized by Ibn Abi S. ādeq Neishaburi, known as Buqrāt thāni. An illustrative example is the six commentaries written by Ibn Rid. wān on Galen’s books, despite the fact that Ibn Rid. wān criticized commentary literature as the cause of the decline of medicine: ‘Summaries fail to encompass all Galen’s ideas, while commentaries increase the length of the art, and distract [students] from studying, since, of necessity, these would have to be read for verification together with their [original] works.’40 The forms of question and answer or reproducing medical aphorisms in the form of poems represent other ‘pre-Islamic’ literary formats adopted by Islamic physicians. One of the ophthalmologic treatises of Hunayn, the Masā’il fi l-‘ayn (Book of Questions on the Eye), on the physiology and pathology of the eye, was couched in the form of question and answer,41 as was another major work by Hunayn, Masā’il fi l-t․ibb (Questions on Medicine). Commentaries on a master’s books constitute perhaps the bulk of this literature in Islam and were popular in the medical circles of late Antique Alexandria.42 Sometimes treatises were written by eminent physicians with exactly the same titles as those of their Greek predecessors. Rāzi wrote a tract called Man lā yah. d. uruhu Tabib (He Who Has No Physician to Attend Him), following Rufus and Oribasius.43 This method continued into the modern period. In the eighteenth century, ‘Aqili wrote the Maj ma‘ al-javāme‘, a medical digest containing all necessary information in classical order. The abridged (saghira) and extended (kabira) formats of vabā’iyye (on cholera) of Shirāzi in the mid-nineteenth century44 are reminiscent of the Small and Large Compendiums by Ibn Sarābiyun in the ninth century.45 Along with the external configuration of medical texts, different medical paradigms developed by the Greek, and particularly Alexandrian, schools of medicine, including clinical medicine, anatomy, and surgery, and the relationship between magic/religion and medicine, were introduced. The Alexandrian School was home to an intellectual movement much influenced by Aristotle and the dogmatics who laid emphasis on the importance of anatomy. Unlike Rufus, who focused more on clinical and bedside medicine, Galen reconciled philosophy, clinical medicine, and anatomy, producing a synthesis of various tendencies, such as dogmatism and empiricism, as well as various approaches found among the Hippocratics.46 This synthesis is important because during the Hellenistic period these tendencies were irreconcilable to the extent of being considered as antagonistic sects. Even the Hippocratic authors were not unanimous on humoral theory.47 Controversies divided also Islamic physicians. Mirzā Qāzi ibn Kāshef, writing in the seventeenth century, in his Commentary on the work of ‘Emād al-Din Mahmud on china root, contended that matters are not made of one quality but of a combination of different humours and qualities, and therefore treating diseases by prescribing a drug of opposite quality (cold, hot, wet or dry) was not appropriate. For instance, china root is hot according to the perceived opinion but it is used to treat syphilis (atashak) that is also hot, which is a contradiction in principle. The fact, however, is that china root, like many other matters such as lentil, rose, or wine, is morakkab-alqovā (composed of different qualities).48

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Magic and medicine Magic and incantation were the dominant features of medical outlook in pre-Islamic Arabia. The epidemic of plague in 541, for instance, was attributed to jinn, commissioned by the enemies. A person affected by fever was considered to have been penetrated by a supernatural spirit. These beliefs corresponded to the idolatry culture and worship of objects and gods, which was opposed by the new monotheist religion preached by Mohammad. It comes thus as no surprise to see that Islam opposed animism and incantation.49 However, this opposition was religiously or politically inspired and for this reason magical outlook in diagnosis and healing was simply dressed in the new Islamic garb: God replaced magical objects. Since He sent disease, He was the only one who could remove it.50 Just as in the plague of the middle of the sixth century, magic played a significant role in popular responses to the Black Death in the fourteenth century.51 The outcome was the reconciliation of the old custom with the newly introduced medicine based on humoral physiology, epitomized in the medicine of the Prophet. This phenomenon set a theoretical framework for blending or juxtaposing rational and irrational medicine in Islam. In the middle of the nineteenth century, Mirzā Musā Sāvaji devotes the first part of his treatise on vabā (cholera) to the standard medical methods of healing, based on humoral theories, and the second part to prayers and cryptograms and ‘letter magic’ for both prevention and treatment of cholera.52 The systematic and sustained juxtaposition of rational and magic medicine in Islamic medical literature bears witness to the style borrowed from Greek literature while tapping into the abovesaid cultural and social heritage. Magic did exist in Galen’s works, although in a reserved and moderate form in regard to medical treatment. However, Alexander of Tralles (late sixth century) allowed free rein to these irrational tendencies alongside exposing Galenic teaching.53 Likewise, one finds close similarities between medical tracts, such as the Mokhtas. ar-e mofid and Khavās. s. al-ashyā᾽, in which the magic effects of objects and items are underlined in the treatment of diseases,54 and the book of Xenocrates of Aphrodisias (c.70 ce), ‘who recommended cures based on sympathetic magic using parts of organs, secretions and secreta from men and animals’.55 Rāzi also occasionally recommended treatment by sympathetic magic.56

Anatomy and surgery Anatomy is the theoretical knowledge of the structure of the body, obtained through practice of dissection, for the benefit of surgery, pathology, and medical treatment. All these branches of medicine were dealt with in the works of Hippocrates and Galen as translated into Arabic. The books on dissection translated into Arabic included The Great Book on Dissection,57 Dissection of the Dead Animals, Dissection of the Living

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Animals, On Hippocrates Knowledge of Dissection, and Aristotle’s Knowledge of Dissection.58 But none of these texts appears in the Summaria Alexandrinorum, which comprised the textbooks of medical students in Islam. Galenic discourse on the importance of anatomical knowledge, acquired through dissection, was always emphasized by Islamic physicians. However, such an emphasis was not to respond to the necessity of practical dissection. While commentaries or compendia, such as the Canon of Avicenna and the Kāmel al-S. enā‘a of al-Majusi, include chapters on anatomy, Islamic physicians did not author even one book similar to Galen’s books on dissection. The purpose of anatomy was to know the place and location of nerves, veins, and bones to avoid mistakes in bloodletting or bone-setting. The aim of acquiring knowledge of the body was also to be aware of the miracles of Creation and to be able to receive the knowledge of God.59 Anatomical knowledge in Islamic literature was entirely based on Galen’s findings, and anatomists did not seem concerned to make it clear that ‘since Galen had observed perfectly the body and described it, they do not need to undertake dissection of their own.’60 It is highly significant that Rāzi, in his ‘Examination of Physicians’ (Mih . nat al-at. ibbā wata‘yeenihi), specifies that in addition to theoretical and practical knowledge, students should also have knowledge of anatomy, vivisection, and astronomy.61 However, as far as we know there is no record indicating that Rāzi himself undertook any vivisection or even dissection of humans or animals. It appears that Rāzi points to dissection or vivisection, not because he found it necessary, but because Galen had indicated this necessity in his treatise on ‘Examining Physicians’.62 The Tashrih . -e Mans.uri of Ibn Elyâs is the only book that contains diagrams of veins, bones, and nerves not found in Galen’s books. In some copies, illustrations of the fetus are added. However, it seems that Ibn Elyâs took these illustrations from the work of Paul of Aegina (c.625–90 ce), just as Abul-Qāsim al-Zahrāwi (936–1013) drew his surgical materials mainly from the sixth book of Paul’s Epitome.63 The only anatomical book based on dissection in Islamic medicine, but now lost, appears to be the Kitāb al-Tashrih . by Yuhanna ibn Māsawayh.64 According to Ibn abi Usaybi‘a, referring to an event in the month of Ramad. an 221 (August 836), Ibn Māsawayh was keeping monkeys for the purpose of ‘dissecting them and composing a book on the same subject as Galen’. But he had abandoned his plan because ‘in their bodies the arteries and veins and nerves are too fine’. However, ‘upon receiving a large monkey as a gift from the caliph al-Mu‘tas.im . . . he carried out his plan . . . and there was composed a work which even his enemies found fit to praise.’65 Even the discovery of the pulmonary circulation by Ebn Nafis was based not on anatomical observation but on speculation. It occurred in a chapter of the commentary of Ibn Nafis on the Canon of Ibn Sinā, who, following Galen, believed that the passage of blood from the right ventricle to the left was mainly through invisible pores of the wall separating the two cavities although Galen had also observed that there were minute connections between the branches of pulmonary veins and arteries.66 Ibn Nafis contended that: when the blood in the right cavity becomes thin, it must be transferred to the left cavity where the pneumata is generated. But there is no passage between the two

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cavities, neither visible nor invisible, as Galen has thought . . . It must, therefore, be that when the blood has become thin, it is passed into the arterial vein (pulmonary artery) to the lung . . . in order to mix with the air. The finest parts of the blood are then strained passing into the venous artery (pulmonary vein) reaching the left of the two cavities of the heart, after mixing with the air and becoming fit for the generation of pneumata.67

It seems, however, that this insight was accidental in Ibn Nafis’ Commentary. In fact, Ibn Nafis, who was himself a jurisconsult, is explicit that ‘the veto of the religious law and the sentiments of charity innate in ourselves alike prevent us from the practice of dissection. This is why we are willing to be limited to basing our knowledge of the internal organs on the sayings of those who had gone before us.’68 Lack of dissection in Islam has often been attributed to religious prohibition. However, such legal prohibition was not stated in the Koran or even among the sayings of the Prophet; it probably reflected technical or cultural impediments that made dissection impracticable. A parallel obstacle for experimental anatomy and dissection even on animals appears to be of epistemological order. Knowledge, based on inquiry and research, a characteristic of Greek and Hellenistic medicine, was replaced in Islam by knowledge based on tradition, transmission, and the authority of the text. What prevented physicians investigating the inner body was the want of the ‘freedom of scientific inquiry’ that went against vested (religious) interests,69 while the pagan culture of the Hellenistic period left scientific investigations, such as those by Aristotle and Galen, unfettered. Surgery consisted of a wide range of operations from phlebotomy and bone-setting to incision of abscesses and boils, and amputation of organs. Islamic physicians, men of bookish knowledge, never stained their mantle with the blood of surgery. This, however, did not stop them from inserting a chapter on surgery in their books.70 Typical of medieval Islam, even surgery was articulated in letter rather than in the operation room, just as anatomy and dissection were framed in books. Most cases of extreme surgery occurred during war or for the purpose of punishment. In Zakhira ye Kāmela (or Jarrāh. iya), composed some time before 1642, Ḥakim Mohammad includes thirty chapters relating to thirty kinds of injuries or diseases requiring surgical operation. Invasive surgery relates only to two kinds of injuries. Chapter 1 discusses injuries caused by sword, knife, arrow, and gun bullet, and Chapter 6, called siyāsat-e pādeshāh (‘Punishment Ordered by the Shah’), enumerates injuries applied by surgeons to execute the royal order as a means of punishment, which included amputation of hands, legs, and penis, extraction of pupil, or deprivation of sight by approaching the red iron called mil (probe) to the cornea in order to damage the pupil.71 While clinical medicine was popular amongst learned physicians in Islam, surgery was left to unskilled surgeons (jarrāh. ) who often had no anatomical knowledge. Cyril Elgood quotes Amār b. ‘Ali of Mosul as saying that he was accompanied only by two or three students when he operated. Elgood then compares this with the large number of students attending the clinical classes of Rāzi.72 Al-Zahrāwi (Albucasis) celebrated for inventing various surgical instruments, emphasized that in his time a ‘skilled practitioner

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of surgery is totally lacking’, a statement in staggering contrast with the high status of medicine in Islam in the tenth century, when he was writing.73

The medical profession State support was crucial in the formation of the medical profession in Islam. The early Islamic states, the Omayyad (661–750) and Abbasid (750–1258), recruited physicians from the existing medical profession in the regions they had conquered; hence most of them were Christians or Jews. State sponsorship played also an important role in the development of medical knowledge and literature. The state-sponsored translation movement set the model for the medical profession as closely linked to the state or the nobility. As Goitein indicated, almost any doctor of distinction was also a member of the entourage of a king, a sultan, a vizier, or a governor.74 Yahya b. Isā b. Jazlah (d. [473] 1080), for instance, could practise medicine thanks to the position and salary that the chief justice (the qād. i al-qud. āt) of Baghdad offered him, probably because he converted to Islam. He apparently had such an income that he was able to treat patients and even provide them with medicine free of charge.75 Major medical books commissioned by the court or a noble patient were later dispersed through individual copies, either for sale or for personal use. The impact of court medicine on the nature of medical literature is evident in its remarkable concern with dietetics, preservation of health, usefulness of sexual intercourse and the harm caused by its excess, and invention of new compound drugs to increase well-being. The treatise on hygiene by Maimonides, for example, was written for the son of Sultan Saladin, who for a short period occupied the throne of Egypt. Nevertheless, the medical profession was not limited to the tiny number of learned or ranking physicians attending the court or the nobility. According to Rosenthal, the existence of an elite group of physicians indicates that there must have been a broad supporting base offering medical services to a large portion of Moslem society.76 This idea is corroborated by the important number of low-quality copies of famous books, or amateur compilations from other books. Many medical manuscripts are copied or scribed by poor hands and contain orthographic mistakes.77 Most of those who believed that they could master medicine by self-learning used such manuals for medication or treatment of others’ illnesses, a fact that could cause mishap in treatment or medication. Exceptionally one finds brilliant self-taught physicians such as Ibn Rid. wan or Maimonides. The terms used to distinguish between learned physicians who were knowledgeable in both Islamic and pre-Islamic sciences, and those who held basic medical knowledge for practice were, respectively, .tabib or Ḥakim (physician-philosopher) and mutit. abbib (practitioner), although often learned physicians through modesty called themselves mutit. abbib. According to Galen, ‘only he is a perfect physician who is at the same time a philosopher.’78 In practical terms, however, one can hardly attribute a definite level of knowledge or skill to each category, not least because there was no standard method for learning.79

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The number of physicians able to master the books indicated above or even afford them for study was limited. On the other hand, a large number of people contented themselves with small tracts and a basic knowledge of medicine, without having to read and learn classical texts. There are, however, no figures for such practitioners, except anecdotal accounts. According to Ibn al Qifti, ‘the number of those who were successful in the examination in 937 by Sinān b. Thābit b. Qurra, the court physician, amounted to about 860 in addition to those who were so prominent they did not need an exam and those who were serving at the court of the Caliph al-Muqtadar.’80 Considering such educational and social context conditioning medical practice, it is hard to specify the boundaries of the Islamic medical profession.

Lay medical literature Extant medical literature can be divided into learned and lay medical texts. A clear-cut distinction between folk and learned medicines is inaccurate because one finds elements of folk medicine in both learned and lay medical texts. The extent to which Galenic medicine penetrated both learned and folk medicine was due to the fact that it was integrated in the Islamic world-view. Although learned doctors mainly used rational methods to educate and to treat, at times they used magic or irrational methods to heal. In Mokhtaṣar f’il T. ibb, which dealt with curing illnesses and the preservation of health by means of food and diet, ‘Abd al Mālek b. Ḥabib referred to both the traditions of the Prophet and Greek humoral theories.81 Mirzā Musā Savaji, writing in 1853, believed that there were: two causes of epidemics (vabā): a) the distant/heavenly causes (asbāb-e ba‘ida), either the will of God or Destiny or the influence of the planets, in which cases one should seek healing in .sadaqa (alms giving), penitence, invocation, and prayer; b) accessible/earthly causes (asbāb-e qariba), like the putrefaction of the air, the (prophylactic) solution to which was to flee the foul air . . . while they should also have recourse to prayer, s. adaqa, and invocation for warding off affliction alongside other prophylactic measures like evacuation, retention and the use of appropriate diet.82

What, however, distinguished learned from lay medical literature was their quality, originality, and intellectual levels. Sometimes learned physicians wrote treatises destined for different types of readers. Rāzi’s al-Ḥāwi (Continent) and the Jodari va Ḥa.sba (Smallpox and Measles) resulted from his clinical observations over a long period of time. Rāzi also wrote a book entitled Man lā yuh. zar al-T. abib (What to Do in the Absence of Doctor?), which was destined for the common people.83 This book is also called the T. ibb al-fuqarā (Medicine for the Poor), for those who could not afford a doctor. Allāh Ābādi, the author of the Muh ․ibb al at․ibbā, makes it clear in the introduction to this treatise that he wrote it in order for the reader to dispense with the need for a doctor.84 Books like Zād al-Mosāferin (Provision for Travellers) were for use when travelling. Esmā‘il Gorgāni, after his Zakhira (A Medical Compendium), abridged it under the title Khuff-e

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‘Alā’i (The Boots of ‘Alā’i (Exaltation)), for the prince ‘Alā-al-Dowla Khārazmshāh II (r. 1128–57), so that it might be placed in his boots when he went horse-riding.85 The assimilation of humoral theory into folk medicine and the adoption of folk or magic healing by learned physicians were based on existing cultural and religious beliefs that penetrated all layers of the population. In this situation learned physicians did not find it contradictory to pull together magical healing and rational medicine. Perhaps the social framework in which layfolk and learned medicine were combined should be assigned to the fact that the medical profession was institutionally loose. The lack of clear institutional and professional delimitation allowed the combination of various medical ideas and practices just as it favoured close contact and dialogue between learned and unlearned.

Prophetic medicine There are no less than nine works on the medicine of the Prophet and the Imams but only a few are extant or published. Ḥâji Khalifa, writing in 1658, mentions seven works known to him, including those by the Shiite Imām ‘Ali b. Reza (c.765–818) and ‘Abd ar-Rah. mān al-Suyūt. ī (1445–1505). To these should be added works by Shams al-Din al Zahabi (1274– 1348) and Ibn Qayyim al-Jawziyya (d. c.1350/1), to which al-Suyūt. ī frequently refers.86 It ought to be noted that Prophetic medicine was an apocryphal production of later date, narrated through a chain of several generations of scholars of different philosophical or ideological persuasions. Al-Suyūt. ī, for instance, was one of the Shāfe‘i scholars of the fifteenth century and well versed in Greek medicine. The opening chapter of al-Suyūt. ī’s T. ibb al-Nabbi is on the principles of humoral medicine, the preservation of health, and aetiology based on the six non-naturals. As-S. anowbary (d. 1412), on the other hand, in his Book of Mercy on Medicine and Wisdom, makes a brief mention of humoral theory and one reference to Hippocrates and Galen, but devotes most of his book to quotation of h. adiths and to magical and talismanic methods of healing.87 Al-Jawziyya and al-Suyūt. ī under each entry provided a humoral description of the illness, a drug, or a food before relating h. adiths of the Prophet about them. For headache, for instance, after giving its different kinds according to the anatomical location of the pain, al-Jawziyya enumerated their various causes, such as the predominance of one of the humours, stomach ulcer, and inflammation of the stomach veins. Amongst the remedies for headache as narrated from the Prophet, cupping and applying henna are cited. Henna counterbalanced the heat that ascended to the head and caused pain, because it was cold in the first degree and dry in the second.88 The T. ibb al-Nabbi as composed by al-Jawziyya and al-Suyūt. ī is concerned not only with transmitting the traditions of the Prophet, but also with justifying the tenets of humoral medicine by expounding on the sayings of the Prophet. In short, the literature known as Prophetic medicine follows the agenda of Galenico-Islamic medical tracts, with added references to the traditions of the Prophet. Prophetic medicine was not thus a reaction against Greek medicine, but asserted that the tenets of Islam contained all knowledge necessary for the faithful. Prophetic medicine

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was a development within the general trend of assimilating Greek medicine into Islam. The assimilation was reciprocal. Physicians who were trained in, and adhered to, GalenicoAvicennian medicine also introduced religious concepts in their medicine. According to ‘Aqili (eighteenth century), a physician should also learn other sciences, such as jurisprudence (fiqh) and tradition (h. adith), moral philosophy, logic, natural science, geometry, astronomy, arithmetic, and the art of soothsaying and discernment (kahānat va fārāsat).89 Similar associations can also be found in folk medical literature. In the Risāla–ye Dallākiyya, a treatise on bathing, the author shares two divergent opinions: according to the first, bath was the invention of Solomon, and, following the second, it was the creation of the physicians. Infection is sometimes attributed to unclean tools (like towels), or stagnation of water in Ḥammam (public baths), factors that should be avoided. However, the treatise also states that water should be warmed by fire and not brought in from mineral sources because the warmth or heat of mineral sources originated in hell. While the removal of dirt by rubbing unblocks the pores of the skin allowing the transpiration of the body, it also depletes the means (dirt) through which Satan penetrates the body. The tract also warns against the use of the rubbing glove or towels of those infected by contagious diseases.90 Hygiene as usual was braided with religious rituals. Opposition to Greek medicine did not come from Prophetic medicine, but from a perception of medical knowledge and practice developed by ‘traditionalist’ scholars, who were themselves imbued with a ‘rationalist’ spirit. Ghazzāli, for instance, was a philosopher and theologian, who believed in natural sciences, including medicine, and made use of logic and dialectic in his arguments, but contended that natural philosophers (T. bi‘iyun) could not see beyond the nature and the original cause that makes nature work.91 He also argues that ‘knowledge’ is superior to belief and that knowledgeable men are closer to the Prophet than those who believe without knowing.92 Ghazzāli did not reject medicine, but believed that medicine and doctors alone were not able to heal unless correct usage was revealed to the faithful via faith or by the angels. He stated that: People think that [for treating an illness] it suffices that they purchase drug prescribed by the doctor and apply it. This is wrong because prior to any action the best choice of doctor should be revealed to the patient first, and then the best and the most efficient drug, its dose and the time of its use must be revealed to the doctor via divine inspiration. Without faith and heavenly revelation, wrong treatment is mistaken for the right one. And the faith and inspiration cannot be found in any drugstore but in the treasury of the angels. There is no way to buy inspiration from the storehouse of the angles (khazāneh-ye malaekeh) other than by prayer.93

The modern period All the factors that characterized ‘Islamic medicine’ and helped its development throughout the Middle Ages informed also the way it encountered modern Western medicine from the eighteenth century onwards. One crucial factor was state or princely

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support, without which medieval Islamic medicine could not have developed as it did. Likewise, in the modern period, without state sponsorship the introduction of modern medicine was inconceivable. Medical reform was not so much due to the impulse of social and political development as to the authoritative state planning for military modernization. It was the state agenda that brought about quick, and mechanical, rather than conceptual, change. The form, intensity, and extent of medical modernization depended on the structure or the nature of the state authority. In Tunisia, the growing influence of the colonial power by the end of the nineteenth century relegated local physicians to a tolerated status.94 In Iran, the status of local medicine did not decrease but at the same time, modern medicine and Western doctors at the court became increasingly present and respected. In the Egypt of Mohammad Ali, which was not a colonial state, the French Dr Clot-bey undertook modernization under the authority of Mohammad Ali, the ruler of Egypt, and sought to work in harmony with the local medical establishment, for instance by preparing textbooks for the study of modern medicine in Arabic.95 At the end of the century, however, following the British occupation, medical education was deemed archaic and the remedy, according to a correspondent in 1894, was seen in teaching medicine in a European language rather than in Arabic, and in the all-inclusive replacement of the teaching staff of the school.96 Although the conceptual in-road of modern sciences and biomedicine was crucial in sidelining traditional Galenic medicine, institutional factors were no less important. They played an even more important role in the demise of medieval Islamic medicine. Whenever traditional medicine found social, institutional, or cultural support, it survived even though some re-adaptation was necessary. One example is the medicine of the Prophet that is popular among Moslem communities even in the West.97 The survival and wide practice of Ayurveda and Unani (Greek) medicine in the Indian subcontinent was closely linked to the anti-colonial movement. They were used as representative of the national identity and symbol of resistance to colonial sciences and medicine. In countries such as Iran and Turkey, on the other hand, where traditional humoral medicine lost state sponsorship, it was no longer dominant by the midtwentieth century. The major difference between the introduction of Greek medicine into Islam in the Middle Ages and the modernization of Galenico-Islamic medicine in the nineteenth and twentieth centuries seems to be that the former was introduced through the formation of Islam as a religion or worldview, while the latter was integrated through the making of the modern nation-state. Galenico-Islamic medicine, accountable as it was to religion and faith, failed, in its later development, to meet modern conditions. Mohammad-Hosein ‘Aqili, the outstanding physician of the late eighteenth century, when recommending the study of philosophy and dialectic and logic to medical students, insisted that this should not be used against religion but for strengthening the sharī‘a, and a means of its understanding, and not a means of personal and independent inquiry according to one’s own will and opinion.98

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Conclusion Galenico-Islamic medicine followed Greek medicine in style and recycled its content. The strength of learned ‘Islamic medicine’ remains less in its innovations than in its pedagogical capacity. Authors such as Avicenna and al-Majusi were great organizers of the mass of information according to a coherent theory and classification that facilitated their assimilation. The question now is to see why ‘Islamic medicine’ turned medical theories into dogma and froze the spirit of inquiry and observation, which were fundamental in the Hippocratic and Galenic writings by sanctifying the latter. Any new development was delayed until the emergence in the eighteenth century of neo-Hippocratism that advocated a return to Greek sources. This chapter has pointed to the adoption of Greek medicine within the framework of the formation of Islam as one factor in this outcome. No doubt, however, further explanations for such developments need to be found in the intellectual and social history of the Islamic East and the Latin West in the same vein that the emergence of Hippocratic medicine around 400 bce needs to be understood in the context of the profound social transformation of ancient Greece.

Acknowledgements This chapter was prepared as part of research funded by the Wellcome Trust. I am grateful to Lutz Richter-Bernburg for his thorough comments on an earlier version of this paper.

Notes 1. Lawrence I. Conrad, ‘Arab-Islamic Medicine’, in R. Porter and W. Bynum (eds), Companion Encyclopedia of the History of Medicine (London: Routledge, 1993), 1: 676–727; P. Pormann and E. Savage-Smith, Medieval Islamic Medicine (Edinburgh: Edinburgh University Press, 2007), 2; M. Ullmann, Islamic Medicine (Edinburgh: Edinburgh University Press, 1978), xi; D. Campbell, Arabian Medicine and Its Influence on the Middle Ages, Vol. 1 (Mansfield Centre: Martino, 2006), xi; De Lacy O’Leary, How Greek Science Passed to the Arabs (London: Routledge and Kegan Paul, 1979), 5. This edition is also available through Assyrian International News Agency, Books Online: http://www.aina.org 2. F. Rosenthal, ‘Al-Biruni between Greece and India’, in Science and Medicine in Islam, Variorum reprint (1990), 11–12. 3. Arthur John Auberry, The Koran Interpreted (Oxford: Oxford University Press, 1964), 79, 100, and 265–6. 4. Conrad, ‘Arab-Islamic Medicine’, 678–82. 5. G. E. R. Lloyd (ed.), Hippocratic Writings (London: Penguin Books, 1987), 166. 6. The Koran, sura 51/.ayah 56. 7. Conrad, ‘Arab-Islamic Medicine’, 679.

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8. Ullmann, Islamic Medicine, 2. 9. Kamal S. Salibi, A History of Arabia (Delmar, NY: Caravan Books, 1980), 27 ff. 10. The use of mil, or ‘probe’ (from Mele, a Greek term), in surgery is underlined by Pormann and Savage-Smith, Medieval Islamic Medicine, 7–8. 11. Ullman, Islamic Medicine, 2–3, 6. 12. C. Elgood, A Medical History of Persia and the Eastern Caliphate (Cambridge: Cambridge University Press, 1951), 64. 13. Cited in S. Hamarneh, ‘The Physicians and the Health Professions in Medieval Islam’, Bulletin of NY Academy of Medicine 47(9) (1971), 1088–110, at 1090. 14. Ibid. 15. Ibn Sinā, Qānun dar T. ebb [Canon of Medicine], Persian translation, vol. 1: 3–4; MohammadḤossein ‘Aqili, Kholāsat al-h. ekmat [Digest of Medicine], lithograph edn (Bombay, [1261] 1845), 2. 16. A. Z. Iskandar,‘An Attempted Reconstruction of the Late Alexandrian Medical Curriculum’, Medical History 20 (1976), 235–58, at 243. 17. Pormann and Savage-Smith, Medieval Islamic Medicine, 52–3; Y. Tzvi, ‘Another Andalusian Revolt? Ibn Rushd’s Critique of al-Kindi’s Pharmacological Computus’, in Jan P. Hogendijk and Abdelhamid I. Sabra (eds), The Enterprise of Science in Islam: New Perspectives (Cambridge, MA/London: MIT Press, 2003), 354. 18. H ․akim Mohammad Sharif-Khan, Ta’lif-e Sharif, Persian manuscript ([1206] 1792), Wellcome Manuscripts (WMS.) Per. 582, fol. 12. 19. Ḥamarneh, ‘The Physicians and the Health’, 1091. For a debate amongst early Islamic scholars on the qualities of drugs and their classification according to their potency, see Tzvi, ‘Another Andalusian Revolt?’ 20. Mohammad Arzāni, Qarābādin-e qāderi, WMS. Per. 544, fol. 2a. Qarābādin, or aqrābādin, is a corruption of the Greek term graphidion meaning ‘prescription’—Pormann and Savage Smith, Medieval Islamic Medicine, 54. 21. Qānun dar T. ebb, 5: 229–30. 22. Campbell, Arabian Medicine, 4. 23. Emād al-Din Mahmud Shirāzi, Resāleh, Persian MSS, WMS. Per. 293(A), fol. 2. 24. Qānun dar T. ebb, 1: 4. 25. Michael Dols, Medieval Islamic Medicine: Ibn Rid. wān’s Treatise on the Prevention of Bodily Ills in Egypt (Berkeley: University of California Press, 1984), 100. 26. David Pingree, ‘Astrology in Islamic Times’, in E. Yarshater (ed.), Encyclopaedia Iranica (New York: Columbia University, 2008); see online version at http://www.iranica.com/ articles/astrology-and-astronomy-in-iran27. Ullmann, Islamic Medicine, 15; F. E. Peters, Aristotle and the Arabs: The Aristotelian Tradition in Islam (New York: New York University Press, 1968), 35–47, 54. 28. W. Montgomery Watt, Islamic Philosophy and Theology (Edinburgh: Edinburgh University Press, 1962), 42–3. 29. Ullmann, Islamic Medicine, 7; Conrad, ‘Arab-Islamic Medicine’, 695–6. 30. D. Gutas, Greek Thought, Arabic Culture (London/New York: Routledge, 1998), Chapter 2. 31. Elgood, A Medical History of Persia, 37–8. 32. Michael G. Morony, Iraq after the Muslim Conquest (Princeton: Princeton University Press, 1984), 4. 33. Montgomery Watt, Islamic Philosophy, 46; Etienne Gilson, La philosophie au Moyen Âge: des origines patristiques à la fin du XIVe siècle, 2nd edn (Paris: Payot, 1952), 347–9, 352–7.

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34. For a list of Hunayn’s books, see: Dehkhodā, Loghatnāmeh, 6: 9226–7; Lucien Leclerc, Histoire de la Médecine Arabe (Paris, 1876), 1: 143–52. 35. Ullmann, Islamic Medicine, 31, 33–4. 36. Ibid. 36. 37. Peters, Aristotle and the Arabs, 19. 38. Montgomery Watt, Islamic Philosophy, 38–9. 39. ‘Aqili, Kholāsat al-Ḥekmat, 3. 40. Ibn Rid. wān, Useful Book, MS. Tibb 483, 31, ll. 2–18, cited in Iskandar, ‘An Attempted Reconstruction of the Late Alexandrian Medical Curriculum’, 242. 41. Elgood, A Medical History of Persia, 139. 42. Pormann and Savage-Smith, Medieval Islamic Medicine, 15. 43. Conrad, ‘Arab-Islamic Medicine’, 706, 725, quoting Fuad Sezgin, Geschichte des arabischen Schrifttums, vol. 3: Medizin–Pharmacie–Zoologie–Tierheilkunde bis ca. 430 H. (Leiden: Brill, 1970), 65, 154, 258. 44. Mohammad Taqi Shirāzi Malek al-Atebbā, vabā’iyye-h. e S. aqira [Lesser Treaty on Cholera] ([1283] c.1867); vabā’iyye-he kabira [Greater Treaty on Cholera] ([1251] 1835), lithograph edn, Tehran, Library of Majles. 45. Pormann and Savage-Smith, Medieval Islamic Medicine, 35. 46. V. Nutton, Ancient Medicine (London/New York: Routledge, 2004), 140; Ullmann, Islamic Medicine, 21; H. Ebrahimnejad, ‘Jālinus’, in Yarshater (ed.), Encyclopaedia Iranica, 14: 420–7; also available online at http://www.iranica.com/articles/jalinus 47. Lloyd (ed.), Hippocratic Writings, 27. 48. Montakhab az resālah –ye Mirzā Qāzi, WMS. Per. 293 (B), 1–4. Similarly, Hakim Mohammad Hāshem Tehrāni, writing about china root, calls into question the principle of treating a disease by the drug of a temperament opposite to that of the disease by stating that teriaq is hot but is beneficial also for diseases of hot temperament (Eyn al-h ․ayāt dar sharāyet․-e chub-e chini, WMS. Per. 352, Fol. 6). 49. Conrad, ‘Arab-Islamic Medicine’, 683–4. 50. M. Dols, The Black Death in the Middle East (Princeton: Princeton University Press, 1977), 121–2. The saying attributed to the Prophet, ΀΍ϭΩϟ΍ Ϟίϧ΍ ΀΍Ωϟ΍ Ϟίϧ΍ ϱΫϟ΍ ϦΎϔ (‘The one who sent disease sent also its remedy’) echoes this concept. 51. Dols, The Black Death, 122. 52. Mirzā Musā Sāvaji Fakhr al-Atebbā, Dastur al-at. ebbâ fi ‘alāj al-vabā [Prescription of Physicians for the Treatment of Cholera] ([1269] 1852), lithograph edn, Tehran, Library of Majles. 53. Ullmann, Islamic Medicine, 22; Conrad, ‘Arab-Islamic Medicine’, 682, 688. 54. Anonymous Persian manuscript, Medical Library of UCLA, MS 80 ([1240] 1824), fols. 3–48; Hakim Mohammad Beg, Khavās. s. al-ashyā’, WMS. Per. 10, fols. 3–9. 55. Ullmann, Islamic Medicine, 19. 56. Ibid. 44. Supernatural healing could be seen in almost all human societies. The practice of seeking cure during sleep with the hope of visiting the spirit of the healer in a dream, or leaving the sick at the temple of the healing god in ancient Greece, can be seen amongst Jews as well as Moslems—Max Meyerhof, Studies in Medieval Arabic Medicine, ed. by P. Johnstone (London: Variorum, 1984), Chapter 8, ‘L’oeuvre médicale de Maimonide’, 136. 57. This book has been translated into English from the extant Arabic version: Galen, On Anatomical Procedure, trans. by W. L. H. Duckworth, ed. by M. C. Lyons and B. Towers (Cambridge: Cambridge University Press, 1962).

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58. The Fihrist of al-Nadim: The Tenth-Century Survey of Muslim Culture, ed. and trans. by Bayard Dodge (New York: Columbia University Press, 1970), 2: 682–3. See also Ibn al Qifti, Târikh al-h. okamā, Persian translation of 17th-cent. edn, ed. Bahman Dârayee (Tehran: University of Tehran Press, [1371] 1992), 179 ff. 59. C. Elgood, Safavid Surgery (Oxford: Pergamon Press, 1966), 23; ‘Agili Kholās. at al-hekmat, lithograph edn (Bombay, [1261] 1845), 4. 60. It is significant that even for refuting Galen’s theory of the passage of blood between the two cavities of the heart, Ibn Nafis explicitly relied on Galen’s anatomical dissection. 61. Cited in Gary Leiser, ‘Medical Education in Islamic Lands from Seventh to the Fourteenth Century’, Journal of the History of Medicine and Allied Sciences 38 (1983), 48–75, at 68. On Rāzi see also Lutz Richter-Bernburg, ‘Abubakr Muh. ammad al-Rhazi’s Medical Works’, Medicina nei Secoli 6 (1994), 377–92. 62. Albert Z. Iskandar, ‘Galen and Rhazes on Examining Physicians’, Bulletin of the History of Medicine 36 (1962), 362–5. 63. Campbell, Arabian Medicine, 12. 64. Ibn al Qifti, Tārikh al-Ḥokamā, 514. Al-Qifti cites only one book on anatomy, but Ibn abi Us․aybi῾a names another book of Masawayh on anatomy, The Book of the Formation of Man and His Various Parts, on the Number of the Muscles, Joints, Bones, and Blood Vessels, and on the Causes of Pain (Elgood, Safavid Surgery, 24). 65. Cited in Elgood, Safavid Surgery, 24. 66. Pormann and Savage-Smith, Medieval Islamic Medicine, 47; M. Meyerhof, ‘Ibn An-Nafis (XIIIth cent.) and His Theory of Lesser Circulation’, in Studies in Medieval Arabic Medicine (London: Variorum, 1984), 100–1. 67. Cited in Toby E. Huff, The Rise of Early Modern Science: Islam, China and the West (Cambridge: Cambridge University Press, 2003), 168. 68. Elgood, Safavid Surgery, 25; Huff, The Rise of Early Modern Science, 169; Conrad, ‘ArabIslamic Medicine’, 712. 69. Huff, The Rise of Early Modern Science, (1993 edition), 1. 70. Techniques of surgery and surgical operations constitute a chapter in almost every compendium. See, for instance, the Zakhira of Jorjāni and the Canon of Ibn Sinā. 71. Ḥakim Mohammad, Zakhirah-ye kāmela, Persian manuscript ([1209] 1794), Library of the University of Tehran, no. 8825. 72. Elgood, Safavid Surgery, 19. 73. Albucasis, On Surgery and Instruments: A Definitive Edition of the Arabic Text with English Translation and Commentary, trans. M. S. Spink and G. L. Lewis (London: Wellcome Institute of the History of Medicine, 1973), 2 ff. 74. S. D. Goitien, ‘The Medical Profession in the Light of the Cairo Geniza Documents’, Hebrew Union College Annual 34 (1963), 177—cited in Franz Rosenthal, ‘The Physician in Medieval Muslim Society’, in Science and Medicine in Islam: A Collection of Essays (London: Variorum, 1991), 477. 75. Ibn al Qifti, Tārikh al-h. okamā, 498–9. 76. Rosenthal, ‘The Physician in Medieval Muslim Society’, 477. 77. Mofradāt-e Hendi (Simples from India), WMS. Per. 519. 78. J. Schacht and M. Meyerhof, The Medico-Philosophical Controversy between Ibn Butlan of Baghdad and Ibn Ridwan of Cairo, Faculty of Arts publication 13 (Cairo: Egyptian University, 1937), 77. 79. Leiser, ‘Medical Education in Islamic Lands’.

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80. Ibn al Qifti, Tārikh al-h. okamā, 265–6. 81. David Waine, ‘Dietetics in Medieval Islamic Culture’, Medical History 43 (1999), 228–40: 233. 82. Fakhr al-Ḥokamā va Zubdat al-Ateebbā Ḥāji Mirzā Musā Savaji, Dastur al-atebbā fi ‘alāj al-vabâ, lithograph edn (Tehran: Majles Library), 43–6. 83. Conrad, ‘Arab-Islamic Medicine’, 706. 84. Allāh Abādi, Muh. eb al-Atebbā, Persian MSS, WMS. Per 353, 1. 85. Elgood, A Medical History of Persia, 259. 86. Cyril Elgood, T ․ibb-ul-Nabbi or Medicine of the Prophet, Osiris 14 (1962), 33–192, at 40–1. 87. Pormann and Savage-Smith, Medieval Islamic Medicine, 74. 88. Ibn Qayyim al-Jawziyya, The Medicine of the Prophet, ed. and trans. Penelope Johnstone (Cambridge: Islamic Text Society, 1998), 63–8. See also Jalalu’d-Din Abd’ur-Rahman Al-Suyūt.ī, Medicine of the Prophet (London: Ta-Ha, 1994), 100–1. 89. Mohammad Hādi al-‘Alavi al-‘Aqili-ye Shirāzi, Kholās․at al-h. ekmat (Bombay, [1261] 1845), 7. 90. Karim b. Ebrahim, Resālah-ye dallākiyya, Persian manuscript, National Library, St Petersburg, no. 434, fols. 6a, 7b, 23b, 24, 27, 43a. 91. Ghazzāli, Makātib-e Fārsi, 64. 92. Ghazzāli, Book of Knowledge, section I, available at http://www.ghazali.org/works/bk1sec-1.htm 93. Mohammad Ghazzāli, Fazā’el al-ānām min rasāyel h. ujjat al-eslām (or makātib-e fārsi-ye Ghāzzāli) (Persian writings of Ghazzāli), ed. Abbas Eqbāl (Tehran: Ebne Sina, [1333] 1954), 63. 94. Nancy Gallagher, Medicine and Power in Tunisia, 1780–1900 (Cambridge: Cambridge University Press, 1983), 1. 95. Anne Marie Moulin, ‘Disease Transmission in Nineteenth-Century Egypt’, in H. Ebrahimnejad (ed.), The Development of Modern Medicine in Non-Western Countries (London/New York: Routledge, 2009), 44. 96. ‘Medical Education in Egypt’, British Medical Journal (7 July 1894). 97. Conrad, ‘Arab-Islamic Medicine’, 717–18. 98. ‘Aqili, Kholās. at al-h. ekmat, 6.

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Good, B. J., Medicine, Rationality, and Experience: An Anthropological Perspective (Cambridge: Cambridge University Press, 1994). Gutas, D., Avicenna and the Aristotelian Tradition: Introduction to Reading Avicenna’s Philosophical Works (Leiden: Brill, 1988). Jacquart, D., and F. Micheau, La médecine arabe et l’occident médiéval (Paris: Maisonneuve et Larose, 1990). Maddison, F., and E. Savage-Smith, Science, Tools and Magic, 2 vols (Oxford: Oxford University Press, 1997). Newman, A., ‘Tashrih. -e Mans․uri: Human Anatomy between the Galenic and Prophetical Medical Traditions’, in Ž. Vesel et al. (eds), La science dans le monde iranien à l’époque islamique (Tehran: Institut Français de Recherche en Iran, 1998; 2nd edn, 2004), 253–71. Pormann, P. E., ‘La querelle des médecins arabistes et hellénistes et l’héritage oublié’, in V. Boudon-Millot and G. Cobolet (eds), Lire les médecins grecs à la Renaissance: Aux origines dé l’édition médicale, Actes du colloque international de Paris (19–20 septembre 2003) (Paris: De Boccard Edition-Diffusion, 2004), 113–41. Savage-Smith, E., ‘Attitudes toward Dissection in Medieval Islam’, Journal of the History of Medicine and Allied Sciences 50 (1995), 67–110. —— — , ‘The Practice of Surgery in Islamic Lands: Myth and Reality’, in Peregrine Horden and Emilie Savage-Smith (eds), The Year 1000 (2000), 307–21. Temkin, O., Galenism: Rise and Decline of a Medical Philosophy (Ithaca, NY: Cornell University Press, 1973).

chapter 11

m edici n e i n w e ster n eu rope h arold j. c ook

Attempting a short introduction to medicine in Western Europe can be daunting. It is quite a different project from summarizing what is sometimes called the Western medical tradition.1 The phrase ‘medicine in Western Europe’ encourages discussion of the multiplicity of sometimes rapidly changing practices that have always surrounded the maintenance of health and treatment of illness, whereas the ‘Western medical tradition’ suggests a coherent body of ideas and practices persisting for many centuries that made Western Europe special. Of course, from the beginning of written records in Europe, authors showed an awareness of texts and traditions from previous generations, often commenting explicitly on their predecessors, a literary legacy conveyed to many other regions via settlement, colonialism, imperialism, and adaptation. In recent centuries, the literary legacy of Greece and Rome, and Christianity, helped to create an idea of a common ‘European’ heritage, in medicine as in other aspects of life. Since the late nineteenth century, great medical libraries have been founded in Europe, Britain, and the Americas in order to associate modern medicine with this learned tradition. During the Cold War, ‘the West’ came to stand for an expansive form of civilization that united western parts of Europe, Canada, the USA, and Japan in a system of progressive ‘development’ based on technology and science underpinned by democratic institutions.2 The Western medical tradition was therefore meant to indicate the best parts of the medicine of Western civilization as it first took root in antiquity, blossomed in the Renaissance and Enlightenment, and found fruition in progressive modernism. Indeed, ‘modern medicine’ itself held out a large part of the West’s promise for humankind’s material and moral betterment. Since civilizations were considered to be very large groupings based on canonical textual traditions,3 the Western medical tradition was organized according to certain key ideas. These were said to originate in the ‘rational’ medicine of the Hippocratic tradition and its heirs in classical antiquity, picked up and reformulated in the first few hundred years of the Islamic world, then passed back to Europe by translation and commentary

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in the Middle Ages, analysed and purified in the Renaissance, and then built into scientific medicine from the seventeenth century onwards, through the Paris clinics and German laboratories, English sanitary innovations, and American research institutions, to yield the powerful biomedicine of today. To this core intellectual history, scholars have added historical accounts of professionalization, disease, and, most recently, class, gender, race, and the patient’s point of view. Most historians of medicine, and a very large group of medical professionals, have developed skills of textual criticism and archival research in order to teach and write about the Western medical tradition, which has framed almost all accounts of medicine’s histories, even when they have set out to counter it or to add experiences of other ‘traditions’ to this narrative.4 However, if the Western medical tradition can be regarded as a construct, finding other ways to retell a coherent account of the history of medicine in Western Europe is no easy task. ‘Medicine’ is itself a problematic category, being an abstraction built upon a rich variety of activities that differed considerably across both time and space. Moreover, the region itself is hard to define: what we now call Europe has no clear geographical boundary to distinguish it from Asia, nor is there a line between Eastern and Western Europe. The closest to a natural division is linguistic, with Western Europe being the shifting and permeable territory in which Germanic, Romance, and Celtic languages are predominant. Then, too, Western Europe has always been connected to the rest of the world. The proportion of territory lying within a few days’ travel of the sea is great, while the many navigable rivers means that very few parts of the subcontinent can be considered landlocked: it was relatively easy to move people and goods from place to place, and to reach across the surrounding seas and Eastern steppes to other regions and peoples, so that even in the modern period of ‘scientific’ medicine, the commercial, colonial, and imperial relations of Europeans with other regions helped to shape European medicine.5 No master narrative of medicine in Western Europe is possible, then. What is attempted below is rather to locate one main theme in order to gain an impression of change in a general region. It points to one of the ways in which some medical activities in Western Europe were channelled in ways unlike most other regions of the world: the legal form of a ‘corporation’ grew rapidly in the past millennium, making many informal social institutions into self-conscious and stable bodies. It was such formal institutions, from guilds, universities, and colleges of physicians to hospitals, laboratories, and collective but ‘private’ businesses, to which much of what is taken as special about medicine in Western Europe can be attributed: the embodying and empowering of a collective ‘tradition’ handed down the generations in each body that was also capable of adapting to critical challenges without losing its identity because it was more than a set of ideas, practices, and individuals.

Custom and use Western Europeans have always been connected to other places. Indeed, the first agriculturalists had moved into Eastern and Central Europe from the Near East around 5500 bce, while the major Indo-European languages of Western Europe (Celtic, Germanic,

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and Italic) had been introduced by the late second and first millennia bce from parts far to the East. Early Bronze Age metallurgy, also invented elsewhere, could be found in the Iberian Peninsula by around 2400 bce, and throughout Western Europe over the course of the next 1,000 years. Presumably, such people sought help when the need arose where they could—mainly in consultation with family, friends, neighbours, and people in the community who had a reputation for medical knowledge or practice—and often obtaining it. The case of the recently discovered Neolithic ‘iceman’ given the name Ötzi, who lived about 5,000 years ago, is instructive: he had on him a birch fungus that may have been useful as an antibacterial and perhaps as an anthelminthic (anti-worming agent). More surprisingly, perhaps, Ötzi’s body also had tattoos over his lower spine, behind his left knee, and on his right ankle, which have been suggested as spots marking points for something to be inserted to relieve pain. If this is, as some have argued, an early form of acupuncture, it indicates that some medical practices were common across Eurasia.6 The hint of practices widespread throughout large regions should not surprise us, since people had not only come to Europe from far distances but engaged in certain kinds of commerce that moved precious objects across lengthy human chains of contact. Later immigrants established cities and composed written records, some of which are extant. Romans, for instance, mainly encouraged a domestic medicine that combined empirical methods with religious practices, documented in parts of some handbooks written for male heads of households. Indeed, in the case of one of the greatest such compilations, by Celsus (fl. c.25–c.50 ce), only the medical parts remain, commonly going by the title De medicina (On Medicine). While it contains much information about what people like Celsus himself knew and thought about medicine elsewhere, as among the Greeks, on the whole his work mainly offers practical advice of a mixed religioempirical kind about treatments—quite in line with the approach of his fellow encyclopaedist, Pliny the Elder, who also wrote of the medicinal virtues of various substances. However, Greek-speaking immigrants, who were known for their philosophical agility, also came to Rome from the East: Archagathus is said to have arrived about 219 bce and to have been given citizenship because of his medical abilities, while about a century later, Asclepiades of Bythnia made his reputation as an outstanding ‘dietetic’ physician, that is, the kind of doctor who argued that he understood the underlying causes of natural events, and so could advise on how to live in accordance with one’s true constitution in order to maintain or restore health. However, philosophy also grew more respectable among Romans, and in the year 46 ce citizenship was offered to Greek doctors and teachers in Rome, while other major cities within the empire came to appoint municipal physicians conversant in philosophical medicine to help the poor and advise the magistrates. Indeed, Greek philosophy grew well enough for a Greek-speaking philosopherphysician, Galen of Pergamon, to travel to Rome around 161 ce, where he became famous. Over the next fifty years or so he wrote many books, which were so encyclopaedic in character, so astute in formulating questions and answers in clear and precise philosophical language, and so venomous against his rivals, that few of the works of his medico-philosophical predecessors or contemporaries survive.7

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There were also many new remedies introduced from abroad to Western Europe during the Roman period, flowing in over long-distance trade routes. For instance, cloves and pepper—both from South East Asia—seem to have first appeared in Roman receipts for cooking and medicine around the first century ad. Pliny knew of cane sugar starting to be grown in Egypt after arriving from South Asia, but it was too expensive to be used except as a medicine. It was never easy to match what was known about the medical uses of plants, animals, and minerals with general philosophical principles about the functioning of the body, however. Like encyclopaedic works, then, written pharmaceutical information—even that of the famous compiler Dioscorides (c.65 ce), who listed approximately 600 simples—remained empirical, with sources and underlying meanings that are still difficult to decode.8 The ‘decline of Rome’ (evidenced in the sacking of the city in 410) also meant a decline in written medical sources. An in-depth knowledge of ancient philosophical learning, including Greek medicine, remained alive in the Eastern parts of the Roman Empire, but only elements of it remained in the Latin West. One of the places where some basic written traditions about philosophy and learned medicine was retained was the Christian Church. A founder of a monastic group in Italy, Cassiodorus (480–575), wrote down a set of rules that included the requirement to copy texts, ensuring that some literature would survive; such monasteries also set up schools and had infirmaries for the care of inmates and pilgrims. However, the main focus of Christian efforts remained the further development of their religious ideas and practices; indeed, there was a growing reaction against ‘pagan’ philosophy. When around 600, Isidore, Archbishop of Seville, attempted a summary of all knowledge, including learned medicine, in his Etymologies, he was able to squeeze everything into a length amounting to perhaps 300 modern printed pages. By the end of the next century, Western European trade with other places reached a nadir. Since most people relied on local medicines and customary practices, these changes probably indicate little alteration in their resources, although the increased levels of local violence and population decline north of the Alps from perhaps 12 million in 200 to about 10 million in 600 must have made for some grim moments in many lives. By around 800, imported spices were again being noticed in Northern Europe, used more for medicine than cooking, and the first drugs related to Arabic pharmacology also began to appear, suggesting that with the revival of urban commerce the pharmacopoeia was expanding. When Anglo-Saxon handbooks began to be written, they were like their Roman predecessors in many ways, including containing a great deal of information about medicines, as well as charms, amulets, and other curative practices.9 The following centuries brought relative prosperity and a doubling of population between 1000 and 1348. By the later tenth century, a person like Gerbert could acquire a good foundation in Latin classics at his monastic school, put his talents for learning and administration at the service of various powerful political masters, help the Archbishop of Rheims revise and expand the monastic curriculum in the seven liberal arts, and rise to become Pope (as Sylvester II). Some of his followers in southern Italy—a region mixing Latin, Byzantine, Islamic, and Jewish cultures—helped to lay the foundation for an intellectual

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renaissance in the second half of the eleventh century around the ancient Benedictine abbey of Montecassio and the nearby archbishopric of Salerno, where Graeco-Latin sources were arranged and epitomized for teaching. One of the translators there, Constantinus Africanus—a merchant born at Carthage in North Africa who had travelled for many years in the East—developed what became a legendary reputation for medical translations from Arabic to Latin produced between about 1077 and 1087. In the next century, Gerard of Cremona became the most famous of the translators, working with Arabic- and Hebrew-speaking colleagues in the religious borderlands of Iberia to make available Latin texts of both ancient and Islamic works, including medical works of Galen, Ibn Sinā’s Al-Qānun, and al-Rāzi’s al-Hāwi. The early history of medicine in Western Europe therefore saw people mainly reliant on local skills and resources, and oral traditions, supplemented from time to time by the availability of texts and practitioners who devoted themselves to medical learning and practice. Medical knowledge might be passed down in families or through apprenticeships. Anyone with a personal interest in finding out more about what could be known through the study of various texts and traditions could set off on the road, inquiring after teachers of reputation and moving on again when they thought the time was right, perhaps eventually settling somewhere and taking on pupils themselves. While there might be ‘schools’ of thought, there were no formal medical schools, degrees, or licences, only a range of medical practitioners, from the blacksmith who might set broken bones to the local wise woman who knew herbs and spells, to merchants who sold drugs and self-proclaimed philosophers who could read (and sometimes write) medical books, many based on the wisdom of previous generations who lived in far-off lands. Given the widespread movement of people, medicines, and even ideas, few places were cut off from the rest of Europe or the rest of the world: indeed, from what can be discerned about long-distance medical trade and efforts to translate Arabic texts into Latin, medicine was a part of life that showed how willing people were to borrow and adapt if the opportunity occurred.

Corporations and formulations One of the consequences of the revival of learning that would change the nature of organizations in Western Europe was the development of something that formalized medical groups in ways unknown elsewhere: the corporation. While the word is used loosely today mainly to indicate large business concerns, it is best understood more generally as a legal fiction derived from Roman law allowing a group of people to stand before the law as one person or body (corps). For the particular purposes that brought them together they could sue or be sued, hold property, owe certain defined obligations, and exercise certain defined rights just like a person, but to go on doing so beyond any one person’s lifetime. Inside the virtual body, members also had specified rights and duties. Corporations did not depend on or represent the view of one person, but acted as

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a group according to their governing rules, usually after formal discussion. While medical innovations were produced by individuals, it was very often the acceptance of such innovations by collective and formal organizations, their amalgamation and adaptation to previous work, and their passing on to new generations as good practice that gave them authority. In other words, a new kind of agent or organization now took part in medical interactions, one of long memory and many powers. By the eleventh and twelfth centuries, it was common for cities to have secured their rights as corporations and, within the cities, groups of merchants and craftspeople to have secured theirs through establishing subordinate corporations, in English usually called guilds: in many places, such as London, the right of citizenship (which granted a person the right to come before a city court and to have a voice in electing certain officials) was itself conferred mainly through membership in one of these corporations. The guild in turn acted to protect the privileges of its members against individual interlopers or corporate rivals.10 People in medical occupations could be found in some of the early guilds, who over the next centuries split off and founded their own corporations, particularly those of barber-surgeons, surgeons, and apothecaries (the merchants who imported exotic medicines and spices). Similarly, the founding of the early universities was also the result of teachers or students obtaining corporate rights. At places where large numbers of people gathered to learn from masters—such as at Bologna, a gathering point for teachers of law and their pupils—students banded together to form corporations (around 1150 in this case, using the Latin term universitas). By the thirteenth century, by threatening to withdraw from Bologna as a group, the university gained the right to fix the prices of books and lodgings, to set rules for their education, and so forth; the professors in turn formed their own corporation, or collegium, which set strict requirements for admission to their group, most importantly the ability to teach a subject as judged by their peers. They therefore established what was in effect a hierarchy of licences to teach, which became the degrees of Master of Arts, and Doctor of Laws, Medicine, and Theology. Given the student-run nature of universities at places such as Bologna, Pavia, and Montpellier, teaching tended to emphasize practical studies, particularly law and medicine. Another kind of university came into being further north that gave more emphasis to philosophy and theology, being governed by the masters rather than students. It is best illustrated by the example of Paris, where the Chancellor of the Cathedral of Notre Dame had the right to license teaching in the diocese. As its reputation as a centre of learning grew, however, not all the students flocking to it could be accommodated by licensed instructors, causing many teachers to establish themselves outside the Cathedral’s legal remit, on the Left Bank of the Seine (or Latin Quarter). When in 1200, conflicts between town and gown grew so heated that some students were killed, the King of France issued a legal declaration granting students and their servants special protections and recognizing an independent body of teaching masters. Further conflicts a couple of decades later led the Pope to grant special privileges to students and masters, introducing a formal certificate of learning (the baccalaureate degree), which became an entry ticket into the rapidly expanding bureaucracies of church and state. The division of faculties came to be

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fourfold: arts, medicine, law, and theology. In the three higher faculties, teaching rights were granted and degrees conferred based upon the ability to comment upon and debate the content of ancient philosophical texts from the most up-to-date commentaries, which in medicine were based mainly on works translated from Arabic. The university’s corporation of professed physicians—the medical faculty—not only came to control teaching, but also attempted to regulate practice as well, sometimes fining or even exiling from Paris those practitioners who refused to obey them. Similar conflicts arose in other university towns. The significance of the new corporations can be seen during the deadly pandemic known as the Black Death, which first struck Western Europe in 1348–9 and then returned many times over the next three centuries in epidemic waves. It was first introduced into Genoa by merchants returning from the Black Sea, and then spread outward to most of the rest of Europe. A few locales escaped while others experienced up to 90 per cent mortality, with the total loss of life in Western Europe generally estimated to have been well over 30 per cent. Western Europe’s population would take two centuries to return to pre-plague numbers. By the time of the Black Death, however, universityeducated physicians and apprenticed surgeons and apothecaries could be found in most large cities and in the households of many great men. More importantly to modern eyes, many European cities came to enact quarantine measures overseen by the corporately certified medics in order to prevent anyone suffering from the plague to interact with the healthy. Such steps seem to have been important for gradually limiting the recurrent effects of the disease, until it disappeared from Western Europe. The last major outbreak was confined to Marseilles in 1720. Despite the high mortality rates from epidemic disease in the late fourteenth and fifteenth centuries, commerce and corporations allowed the cities of Europe to continue to flourish, while efforts were also launched to find sea-borne trade routes south and east around Africa to the wealthy spice-producing lands of South and East Asia. Within Western Europe, as military means of domination shifted from feudal levies to the use of engineers and artillery officers, paid from state revenues, taxable commercial activities were encouraged. Some of the profits of commerce were also reinvested in efforts to rediscover the secrets of antiquity, while others supported innovations in machinery, architecture, and the fine arts. By the end of the fifteenth century, as European commercial ventures expanded into the Indian Ocean and beyond, and into the New World, a flood of entirely new information about the world accumulated rapidly, while grave doubts about accepted opinion also gained ground. The confluence of such developments led to what is called the Renaissance, while the spread of materialist values meant that the struggle for the future of Latin Christendom took on renewed vigour, breaking the Church into multiple and competing institutions during the Reformation. For medical learning, the critical textual methods of the Renaissance brought to light many classical alternatives to widely received views, while commercial interests also emphasized the importance of accurate information. At the same time, from Asia and the New World came new substances that their proponents claimed were as good or better for treating diseases than anything found earlier. Examining all these claims required

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physicians to be not only competent in the study of texts and philosophy but also as knowledgeable about natural details as apothecaries, or even more so, causing the first professorship of materia medica to be established at the papal university in Rome in 1514; by the later sixteenth century, almost every university medical faculty with aspirations to conveying up-to-date botanical knowledge sought to have a garden. Municipally employed physicians also asserted their authority over apothecaries by writing pharmacopoeias, which established lists of officially approved simples.11 However, challenges to accepted methods of treatment emerged from similar sources, such as the introduction of guaiac wood from the Caribbean, which became a very well-regarded treatment for syphilis, although china root and then sarsaparilla (also from the Americas) replaced it. Individuals who offered their own medical innovations flourished and often took advantage of the new medium of print to distribute their views. As an example of what to our eyes was a successful innovation, an incorporated French surgeon, Ambroise Paré (1510–90), famously wrote about his experience in treating gunshot wounds in a military campaign, where he ran out of the hot oil with which it was customary to cauterize them, substituting a mild ointment (the receipt for which he had earlier obtained from an empiric), thereby discovering that those treated by cautery did much worse than the others. While not all empirical remedies had a similar success, a great many lent strength to the voices of practitioners who argued that improvements to human health would come from personal experience rather than study in books. For their part, incorporated practitioners took on board some of the innovations, sometimes adapted new practices and ideas, and other times pushed back or even tried to suppress those they considered to be dangerous.12 The most serious challenges to the incorporated medical establishment came from the medical chemists (iatrochemists), whose many successful innovations were often based upon ideas and practices that had no place in the universities or guilds. Partly this was because they fitted badly into the classical tradition. Processes such as glass-making had been known to the Romans, but chemical methods of distillation and other processes of separating substances into their essences (or active substances) and inert matter (or dross) came to Europe in the early medieval period from Asia—probably originally from China—and often bore Arabic names, such as alcohol, alkali, and alchemy. By the thirteenth century, distilling apparatus had become powerful enough to extract the ‘quintessence’ of wine in the form of aqua vita (the water of life), while by the later fifteenth century, all kinds of alcoholic essences (liqueurs) could be extracted from plants, making for powerful cordials (originally, as the name implies, meant to warm and strengthen the heart). Other methods worked with heavy metals such as gold and mercury in order to make them potable, again to strengthen the corporeal powers of the recipient. Many alchemists also struggled to produce a substance called the ‘philosophers’ stone’, or the prime substance from which both gold and the elixir of life could be derived. In the middle of the sixteenth century, the publication of works by a Swiss iatrochemical practitioner and religious reformer best known by his pen name, Paracelsus (1493–1542), became a particular focus for controversy. Thus, while iatrochemistry had the support of many monarchs such as Emperor Rudolph II, Queen Elizabeth I, and King

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Philip II, its un-classical methods and ideas, and its association with heterodox figures like Paracelsus, also caused many religious and political authorities, as well as the medical establishment, to be suspicious about the implications of this branch of medicine.13 Over time, however, corporately affiliated physicians and apothecaries adopted iatrochemical procedures while taming its radicalism with materialism. While one of the best-known chemical authors of the early seventeenth century, the physician and nobleman Joan Baptista van Helmont (1579–1644), further developed Paracelsian ideas about the source of vital powers in the archeus, a professor of medicine at Leiden, Franz de le Boë Sylvius (1614–72), discarded previous speculation about immaterial powers. Based on further experimental investigations—by the mid-seventeenth century chemical teaching was a common supplement to the regular medical curriculum—he wrote about fermentation and effervescence (being the first to clearly distinguish them), and divided material substances into fixed salts, acids, and ‘volatile salts’ (alkalis), which reacted to one another without the intervention of occult powers. The influential textbook published in 1675 by the French royal apothecary Nicholas Lémery (1645–1715) further attacked the ‘superstitions’ of the alchemists and accounted for chemical reactions according to the sizes and shapes of the particles of which material bodies were made. Materialism can also be noticed making in-roads in two other famous areas of medical learning, anatomy and physiology. Dissection to inspect the remains of the deceased had begun both among late medieval nuns and other religious groups who were trying to establish the presence of unusual marks in the bodies of those who might be considered to have been particularly saintly, and among surgeons called on to confirm forensically a cause of death in cases of possible violence; by the fourteenth century, at the university of Bologna, there also developed occasional public lecturing on anatomy to point out the organs described in the texts. By the early sixteenth century, however, medical professors and their students were investigating bodies more closely in order to confirm or deny details found in the freshly edited classical texts, often coming to criticize sharply the ignorance of the past. Most famous for this was Andreas Vesalius (1514–64), who lectured on anatomy at the university of Padua and produced a richly and carefully illustrated compendium of human anatomy entitled De humani corporus fabrica (On the Fabric of the Human Body), first printed in Basel in 1543.14 Within a century, the careful materialism of the new anatomy had led to a radical revision of physiological theory, too, with the experimental finding that the blood moved in a circuit throughout the body without the need for spirit to drive it. The Englishman who published on this in 1628 in De motu cordis et sanguinis (On the Motion of the Heart and Blood), William Harvey (1578–1657), fundamentally challenged the view of interdependent relationships among the organs that had been accepted since Galen’s time, throwing open questions about the purposes of all the bodily parts, and launching a host of new investigations that were carried out at many places. It also raised questions about the causes of the motions, which Harvey refused to speculate about; indeed, he had argued against using older terms such as spiritus. For many thinkers, his account was one of the key ideas that opened up possibilities for offering complete descriptions of the living body as a set of material structures operating more or less self-sufficiently, without

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the need to invoke a soul. René Descartes (1594–1650), for example, took a deep interest in chemistry and anatomy and, based upon the latest research as well as his own investigations, developed a mechanical account of the body.15 At some university medical faculties, then, a subterranean strand of materialism grew up and persisted, becoming a resource for radical new views of humankind. At Leiden, for example, Herman Boerhaave (1668–1738), the most famous medical professor of the early eighteenth century, may have held to a strong personal religious faith, but he taught that true medical knowledge came from attention to the material facts, so that understanding the first causes of things was no business of the physician. Julien Offray de la Mettrie, who had travelled to Leiden to study with Boerhaave, developed ideas about how organic processes in the brain and nervous system could account for all necessary features of life; his book, L’Homme machine (1748), came to be almost universally condemned as a source for radical sensualism and atheism. In opposition, professors like Georg Ernst Stahl (1659–1734) of Halle, and a variety of teachers at Montpellier, continued to be explicit that vital processes could not be explained without invoking animal spirits of some kind, but they, too, considered chemical and physical investigations to be critical in the discovery of new knowledge.16 The sense that true knowledge was tangible also helped to support the rise of surgeons to medical prominence. Much of the growing authority of surgeons came from their usefulness to the state in caring for soldiers and sailors who fought in the numerous wars. However, some came from the surgical techniques developed in the burgeoning hospitals. In France, for instance, after Charles-François Félix (1650–1703) operated successfully on Louis XIV for an anal fistula in 1686 (after practising on numerous hospital inmates), the surgeons gained new legal powers, while under Louis XV and Louis XVI, the Paris surgeons almost became the equals of the university physicians. In their constant encounters with bodies, surgeons also furthered the materialistic point of view.17 New treatments also signified the domestication of ‘folk’ remedies inside corporate medicine. The use of foxglove to stimulate the circulation of the blood, for instance, was introduced to learned physicians by William Withering (1741–99) in a book of 1785, although it started with a complex recipe for dropsy from a traditional healer who worked with charms as well as herbs. Considering that the remedy must derive from a material property of one of the simples in the recipe, Withering finally identified the effects with foxglove (Digitalis purpurea). Two other famous methods derived from folk traditions helped to prevent the spread of smallpox. The first was the practice of inoculation, imported to Britain from the Near East and Africa in the second decade of the eighteenth century by Lady Mary Wortley Montague (1689–1762). In 1798, Edward Jenner (1749–1823) published a much better variation on the theme. Instead of inoculating with a mild form of smallpox, he gave his subjects cowpox, following the example of dairymaids in Gloucestershire, who believed that those of them who had contracted this milder disease would not get smallpox. Jenner’s method, which came to be called vaccination (after the Latin word for cow, vaccus), was quickly taken up and spread throughout the world.

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By the eighteenth century, in other words, the waning power of religious institutions and the growing authority of medical commerce and corporate medical bodies that served the state enabled even the professors to agree that the foundations of medical knowledge had been renewed by empirical and experimental studies and, in some cases at least, that the functions of animal bodies and their treatment could be accounted for without recourse to a disembodied soul. While innovations in practice and pronouncement arose from personal initiative, collective debate within the universities and the growing number of other medical institutions of the period, whose governing structures often gave their members security and confidence, enabled such views to be assimilated and to flourish as a new orthodoxy.

The nation-state and medicalization From the end of the eighteenth to the end of the nineteenth century, Western Europe was transformed by urbanization, industrialization, and colonialism, and from the later nineteenth onwards by nation-states that offered material benefits to large segments of the citizenry, including medical services. Medical materialism provided an evidential and theoretical framework for ‘improvement’ in the conditions of life for Europeans and their fellows, while medical relationships themselves came to depend increasingly on the provision and regulation of public services, from hospitals to health insurance. Informal medical relationships persisted of course, but the redistribution of wealth through taxation, and the control of medical licensing and reimbursement through bureaucratic mechanisms, gave national governments large powers and responsibilities. Their ministers came to see laboratory science and other fields of materialist knowledge as fit devices for making choices about what kinds of changes would most benefit citizens. The state therefore attempted to resolve many problems by placing them under the rubric of medicine, even measuring the success of domestic government itself by counting population figures and disease rates. The ‘medicalization’ of life in the past century and more has therefore come to be seen as an indication of the power of collective expertise in the service of the state. However, in Western Europe, at least, medicalization was possible due to the expansion and proliferation of corporate bodies and professional organizations, who continued to protect the interests of their members and, in their view, their members’ patients. The most powerful cause of change in the modern era has been the demographic revolution, initially spurred by higher fertility rates rather than falling mortality rates, which led to more than a doubling of the population of Western Europe from about 120 million in 1750 to about 265 million in 1850, despite emigration abroad, particularly to the Americas. Population pressures sped the pace of agricultural and industrial revolution, urbanization and emigration, wealth creation and impoverishment. A feared new epidemic disease, cholera, caused a feeling of occasional public crisis after it first appeared in Europe in 1830 (with subsequent outbreaks in 1847, 1853, and afterward).

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Many governments stepped in to promote better poor relief, including medical assistance. As always, Europe’s connections to the rest of the world had major effects: large portions of the taxable wealth of many European countries that made public improvements possible came from overseas trade and colonies. Many state policies depended on the collection of numerical information about the population; regular censuses became mandatory in many countries from the late eighteenth century. Statistical studies blossomed. For example, early in the nineteenth century Louis Villermé (1782–1863) studied public hygiene based on numerical data first gathered from the army, then from prison populations, and finally from Parisian neighbourhoods, trying to understand differentials in mortality rates. He assigned the chief reason for disease (and so mortality) to filth, which he in turn associated with poverty. In 1839, England appointed a Registrar General, William Farr (1807–83), who undertook remarkable studies of the causes of mortality; about the same time, the new chief of the Poor Law Commissioners in London, Edwin Chadwick (1800–90), commissioned an initial report and follow-up study to look into the connections between disease and poverty. His Report on the Sanitary Condition of the Labouring Population of Great Britain (1842) demonstrated the connections between disease and poverty, making a utilitarian argument for public investment in the means to control disease as a method for holding down the poor rates (and so paying for itself). Friedrich Engels (1820–95), a businessman who was radicalized by what he saw and read, drew heavily on Chadwick’s Report in his own manifesto of 1845, The Condition of the Working Class in England, which concluded that since society knew that the conditions under which it made people live brought them to premature and unnatural deaths, their deaths should be considered premeditated murder. By the mid-1850s, municipally appointed Medical Officers of Health appeared in London and soon elsewhere, being the eyes and ears on the ground for government officials. While the details of similar arrangements varied in other countries, everywhere the combination of rising urban populations and the linked burdens of poverty and disease made the gathering of medical intelligence critical to government.18 By the 1850s, the emphasis in arguments about the causes of disease focused on the ubiquitous organic dirt. In Vienna, in 1847, Ignaz Semmelweis (1818–65) demonstrated that washing of hands in a solution of chlorinated lime prevented the spread of organic morbific particles from the mortuary to the birthing clinic. The outbreak of cholera in London in 1854 pointed to something similar when John Snow (1813–58) traced many deaths from the disease to the Broad Street pump and had its handle removed, after which the disease declined dramatically in that neighbourhood. Florence Nightingale (1820–1920) also waged war against dirt and disease in a successful attempt to lower mortality rates in British hospitals during the Crimean War of 1853–6, and made fresh air and cleanliness the first principles of her subsequent campaigns. The great stinks emanating from urban rivers like the Seine and Thames began to be tackled in massive public works projects that channelled organic filth away and piped in clean water. Although it is difficult to estimate precisely how much sewerage and water projects ameliorated the weight of urban disease and death, the example of the city of Hamburg

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in 1892 was a lesson to many, when it was devastated by an epidemic of cholera because it had not sufficiently invested in clean water.19 The shift in thinking from organic dirt to ‘germs’, which began in the 1860s, further aided governments in allowing for a more precise determination of the cause of many communicable diseases. It was in turn the product of a new form of corporate organization: the laboratory team, supported by state, university, and philanthropic funding. The idea also had roots in a series of scientific developments in physiology and chemistry that emerged from universities, hospitals, and agricultural research institutes. Publications in 1838 and 1839 by Matthias Schleiden (1804–81) and Theodore Schwann (1810–82) announced that all parts of living bodies—even teeth—arose from cells; Rudolf Virchow (1821–1902) took this further in the mid-1850s by developing the concept of cellular pathology (thus in his view finally ending humoral pathology), in which the seat of disease was always to be sought in the cell. However, the idea that the causes of disease might themselves be cellular organisms came from a chemist, Louis Pasteur (1822–96), a professor who believed in placing his knowledge at the service of the State. Ingenious experiments concerning the ancient problem of spontaneous generation allowed him to show that micro-organisms did not arise simply from the presence of life-giving air mixed with nutriment, but only from other micro-organisms floating in the air. Even more convincingly, in the later 1870s a German state-sponsored physician, Robert Koch (1843–1910), demonstrated the life cycle of a micro-organism and how it caused the disease of anthrax. During the 1880s and 1890s, increasing numbers of laboratory investigators found a vast range of diseases to be caused by germs.20 The best field for such studies was often found to be in the European colonies.21 Germ theory had large implications for public health. Using government-paid field investigators supported by laboratories, sources of infection could be identified convincingly and cleaned up; waste products could be treated chemically to avoid the circulation of bacteria; the sources of the provision of meat, milk, and other foods could be inspected and withdrawn from commerce if found to harbour dangerous germs; public campaigns could be launched to fight germs in home and kitchen; disease carriers could be identified and treated even if (as in some famous cases of typhoid) they showed no signs of illness themselves. Such measures could be controversial, while some writers, such as Max Joseph von Pettenkofer (1818–1901), a professor of hygiene in Munich, argued that the false optimism of narrowly contagionist arguments like the germ theory would undermine the beneficial effects on health of continuing to fight the causes of poverty and poor living conditions: to make his point, he publicly swallowed a vial of cholera vibrio without ill effects. The new laboratory science nevertheless quickly gained the backing of governmental authorities, who believed that it would alleviate many social problems by preventing the rampant communicable diseases that so devastated the lives of rich and poor alike. The development of laboratory methods as an adjunct to clinical medicine also held out to governments the possibility to educate, sustain, and distribute through society a new kind of scientific doctor. A newly unified medical profession came into being through bureaucratically controlled medical regulation, the provision of health insurance, and

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the development of a hospital medicine used by all parts of the social spectrum. It sometimes pitted eminent clinicians, who wanted to retain their own professional autonomy, against ordinary doctors, who welcomed state finance. However, it also established a relatively expensive and effective scientifically oriented medicine as the standard against which any other alternatives would be judged. Hospitals became one of the chief sites for scientific medicine in the nineteenth and twentieth centuries. In most of Europe, these medical establishments for the sick were part of governmental provision for the poor, but this changed by the end of the nineteenth century. The development of anaesthetic and antiseptic surgery, newly professionalized nursing, and access to the latest techniques of laboratory diagnosis and treatment increasingly caused ordinary people to think of entering hospitals—which had formerly been for the sick poor alone—and paying for treatment there. During the same period, medical staff came to have control over the criteria for admission. The development of a variety of technically difficult diagnostic and treatment regimes turned the attention of admitting doctors to patients who needed specialized services, and doctors in turn became more common members of hospital boards. In all countries of Western Europe, more complicated surgical operations that required special operating theatres, teams of well-trained staff, and special recovery procedures received much attention; but so too did the attached laboratories, which allowed definitive diagnosis in many diseases, radiological procedures following the introduction of X-ray and other electrical devices, blood-typing and blood-banking (after the First World War), and so on. As the ‘best’ medical care became increasingly associated with the ‘most scientifically advanced’, hospitals benefited, and medical practitioners had increasing incentives to gain access to hospitals, or at least to gain admitting rights for their patients.22 Such spaces helped to shape a new kind of medical profession. The details of how a single medical profession arose differed from country to country, but can be observed to be general throughout Western Europe. In Britain, for instance, while the old corporate bodies survived, the Medical Act of 1858 set up the General Medical Council to oversee the certification processes of the various groups and to establish an official ‘list’ of all those so qualified. In the German territories, both certification by universities and examination by the state were common, and by the end of the nineteenth century various laws strictly prohibited the practice of anyone not sanctioned by the state. So, too, governments increasingly regulated methods of reimbursement for their statesanctioned professionals. Between 1883 and 1911, Germany, Austria, Belgium, France, Denmark, Norway, Sweden, and Britain all passed national health insurance legislation, providing reimbursements in cases of sickness, accident, old age, and death. Doctors who wished to participate in the insurance system could often count on a steady income in return for heavy case-loads, although the possibilities for conflict between doctors and bureaucrats over medical treatment also arose. From the early twentieth century, national governments also intervened in the medical market by establishing regulations for foods and drugs. Such measures, coupled with a great investment in sanitation and public health, had important consequences, shifting the burden of disease in the twentieth century from infectious to chronic illness.23

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By the beginning of the twentieth century, then, Western Europe had been ‘medicalized’. Government-sponsored scientific medicine had come to dominate not only measures for the prevention of communicable disease but the provision of health care, the regulation of foods and medicines, and even the possibilities of medical consultation for ordinary people. Stimulated by the crisis of the Second World War and the subsequent ‘welfare state’, medicine in Western Europe continued to become ever more scientized and bureaucratically controlled, although from the later 1960s onward, alternative strategies were at work to encourage a more patient-centred approach within the overall framework of government-provided health care. On the other hand, as governments have come to regulate, pay for, and even control institutions managing the delivery of health care, the corporate groups that have overseen medical education and training, professional ethics and standards, and the approbation of new methods and ideas have come to feel more and more disempowered: fear of the loss of professional autonomy remained powerful in the twentieth century.

Conclusion Simple models of the contemporary world often pit the private sphere against the public sphere, with government provision of medical care contrasted to privately paid care. Obviously, this is far too simple a view. When in need, people still often rely on themselves, family, friends, neighbours, and nearby medical practitioners, whom they may compensate by returning favours or other personal credits, or by payment. But they also turn to ‘regular’ medical practitioners, that is, those regulated by a corporation or government body. Corporations of various kinds have, since the eleventh century, taken on the responsibility of certification and licensing, and inspection and regulation, of their members and other practitioners. Governments—at first municipal, and later national— found it in their interest to enable corporations, and to referee disputes among them, as a means of allying these ‘private’ bodies with a view of the public interest. In more recent decades, patients may seek out only those practitioners allowed compensation through insurance or public payment—which are in turn regulated by national governments or backed by public revenues—or they may simply appear at clinics or hospitals overseen and funded by government. In that sense, the layers of medical assistance continue to range from the personal to the public, and payment to range from the informal to the monetary to a form of public investment. Practitioners and educators themselves, however, remain aware of the importance of professional corporations, which can still mobilize voluntary work on behalf of their members. Western Europeans have always been connected to other places and practices as well, and owe much of their knowledge and wealth to them. But it may be in the legal form of corporate groups, whose members engage in activities that continue to form a kind of citizenship in their institutions, with associated duties and privileges, that one of the most important and enduring legacies of the medicine of Western Europe can be seen, however much they may now be

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considered under threat from new forms of the nation-state. National governments in turn feel as never before an intense public scrutiny on the question of provision of medical services and a public health infrastructure. Medicine is certainly no longer a private affair, although it is not simply a public one, either. It might be possible, then, to say this about medicine in Western Europe: when people inhabiting the region have attempted to prevent, ameliorate, or relieve the ills of body and mind, they have always done so in a variety of ways. However, the development of certain kinds of legal forms as constitutive of public life allowed both for long-lived corporations to come into being and for them to grow into formations that framed the collection of people, activities, and ideas that we call medicine. Medical activities organized around corporate bodies have shaped the recruitment and expenditure of effort and resources so as give rise to a kind of official medicine that has framed discussion of other ideas and practices and has furthered the development of political economies and populations that consider health to be one of the key measures of the good. Perhaps it is possible to begin to imagine a history of medicine in Western Europe that sees ‘ideas’ and ‘practices’ not as distinct subsets of a ‘medical tradition’, but as abstractions flowing from the organization of effort and attention on problems relating to preventing illness and prolonging life.

Notes 1. Lawrence I. Conrad et al., The Western Medical Tradition, 800 bc to ad 1800 (Cambridge: Cambridge University Press, 1995); William F. Bynum et al., The Western Medical Tradition 1800 to 2000 (Cambridge: Cambridge University Press, 2006). 2. For one clear formulation of the ideology, see the later edition of a book first published in 1960, W. W. Rostow, The Stages of Economic Growth: A Non-Communist Manifesto, 3rd edn (Cambridge: Cambridge University Press, 1990). 3. See, for instance, the definition of ‘civilization’ in Marshall G. S. Hodgson, Rethinking World History: Essays on Europe, Islam, and World History, ed. Edmund Burke, III (Cambridge: Cambridge University Press, 1993), 81–5. 4. For some recent examples, see Conrad et al., The Western Medical Tradition; Bynum et al., The Western Medical Tradition 1800 to 2000; Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: Norton, 1998); Jacalyn Duffin, History of Medicine: A Scandalously Short Introduction (Toronto: University of Toronto Press, 1999). For further accounts of the historiography, see Frank Huisman and John Harley Warner (eds), Locating Medical History: The Stories and Their Meanings (Baltimore: Johns Hopkins University Press, 2004). 5. Paolo Palladino and Michael Worboys, ‘Science and Imperialism’, Isis 84 (1993), 91–102; Shula Marks, ‘What is Colonial about Colonial Medicine? And What Has Happened to Imperialism and Health?’, Social History of Medicine 10 (1997), 205–19; Warwick Anderson, ‘Postcolonial Histories of Medicine’, in Huisman and Harley Warner (eds), Locating Medical History, 285–306. 6. L. Capasso, ‘A Preliminary Report on the Tattoos of the Val Senales mummy’, Journal of Paleopathology 5 (1993), 173–82.

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7. Owsei Temkin, Galenism: Rise and Decline of a Medical Philosophy (Ithaca: Cornell University Press, 1973). 8. For a fresh approach, see Laurence M. V. Totelin, Hippocratic Recipes: Oral and Written Transmission of Pharmacological Knowledge in Fifth- and Fourth-Century Greece (Leiden: Brill, 2009). 9. Michael McCormick, Origins of the European Economy: Communications and Commerce, ad 300–900 (New York: Cambridge University Press, 2002), 791; Linda E. Voigts, ‘Anglo Saxon Plant Remedies and the Anglo Saxons’, Isis 70 (1979), 250–68. 10. Antony Black, Guilds and Civil Society in European Political Thought from the Twelfth Century to the Present (New York: Methuen, 1984). 11. Jerome J. Bylebyl, ‘The School of Padua: Humanistic Medicine in the Sixteenth Century’, in Charles Webster (ed.), Health, Medicine and Mortality in the Sixteenth Century (Cambridge: Cambridge University Press, 1979), 335–70. 12. Harold J. Cook, The Decline of the Old Medical Regime in Stuart London (Ithaca: Cornell University Press, 1986). 13. Bruce T. Moran, Distilling Knowledge: Alchemy, Chemistry, and the Scientific Revolution (Cambridge, MA: Harvard University Press, 2005); Charles Webster, Paracelsus: Medicine, Magic and Mission at the End of Time (New Haven, CT: Yale University Press, 2008). 14. Katherine Park, Secrets of Women: Gender, Generation, and the Origins of Human Dissection (New York: Zone, 2006); Andrea Carlino, Books of the Body: Anatomical Ritual and Renaissance Learning, trans. John Tedeschi and Anne C. Tedeschi (Chicago: University of Chicago Press, 1999). 15. Thomas Fuchs, The Mechanisation of the Heart: Harvey and Descartes (Rochester: University of Rochester Press, 2001). 16. Kathleen Wellman, La Mettrie: Medicine, Philosophy and Enlightenment (Durham, NC: Duke University Press, 1992). 17. Owsei Temkin, ‘The Role of Surgery in the Rise of Modern Medical Thought’, Bulletin of the History of Medicine 25 (1951), 248–59; Toby Gelfand, Professionalizing Modern Medicine: Paris Surgeons and Medical Science and Institutions in the Eighteenth Century (Westport, CT: Greenwood, 1980); Laurence Brockliss and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997). 18. Anne Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856–1900 (Oxford: Clarendon Press, 1993); François Delaporte, Disease and Civilization: The Cholera in Paris, 1832, trans. Arthur Goldhammer (Cambridge, MA: MIT Press, 1986). 19. Dorothy Porter (ed.), The History of Public Health and the Modern State (Amsterdam: Rodopi, 1995); Christopher Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854 (Cambridge: Cambridge University Press, 1998); Richard Evans, Death in Hamburg: Society and Politics in the Cholera Years 1830–1910 (Oxford: Oxford University Press, 1987). 20. Gerald L. Geison, The Private Science of Louis Pasteur (Princeton: Princeton University Press, 1995); Christoph Gradmann, Laboratory Disease: Robert Koch’s Medical Bacteriology, trans. Elborg Forster (Baltimore: Johns Hopkins University Press, 2009). 21. Bruno Latour, The Pasteurization of France, trans. Alan Sheridan and John Law (Cambridge, MA: Harvard University Press, 1988); Mark Harrison and Biswamoy Pati (eds), Health, Medicine and Empire: Perspectives on Colonial India (New Delhi: Orient Longman, 2001);

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Warwick Anderson, The Collectors of Lost Souls: Turning Kuru Scientists into Whitemen (Baltimore: Johns Hopkins University Press, 2008). 22. Mary E. Fissell, Patients, Power, and the Poor in Eighteenth-Century Bristol (Cambridge: Cambridge University Press, 1991); Guenter B. Risse, Mending Bodies, Saving Souls: A History of Hospitals (New York/Oxford: Oxford University Press, 1999). 23. Dorothy Porter, Health, Civilization, and the State: A History of Public Health From Ancient to Modern Times (London: Routledge, 1999).

Select Bibliography Brockliss, Laurence, and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997). Carlino, Andrea, Books of the Body: Anatomical Ritual and Renaissance Learning, trans. John Tedeschi and Anne C. Tedeschi (Chicago: University of Chicago Press, 1999). Delaporte, François, Disease and Civilization: The Cholera in Paris, 1832, trans. Arthur Goldhammer (Cambridge, MA: MIT Press, 1986). Evans, Richard, Death in Hamburg: Society and Politics in the Cholera Years 1830–1910 (Oxford: Oxford University Press, 1987). Fissell, Mary E., Patients, Power, and the Poor in Eighteenth-Century Bristol (Cambridge: Cambridge University Press, 1991). Geison, Gerald L., The Private Science of Louis Pasteur (Princeton: Princeton University Press, 1995). Gradmann, Christoph, Laboratory Disease: Robert Koch’s Medical Bacteriology, trans. Elborg Forster (Baltimore: Johns Hopkins University Press, 2009). Hamlin, Christopher, Public Health and Social Justice in the Age of Chadwick: Britain, 1800– 1854 (Cambridge: Cambridge University Press, 1998). Hardy, Anne, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856–1900 (Oxford: Clarendon Press, 1993). Harrison, Mark, and Biswamoy Pati (eds), Health, Medicine and Empire: Perspectives on Colonial India (New Delhi: Orient Longman, 2001). Nutton, Vivian, Ancient Medicine (New York: Routledge, 2004). Park, Katherine, Secrets of Women: Gender, Generation, and the Origins of Human Dissection (New York: Zone, 2006). Porter, Dorothy, Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times (London: Routledge, 1999). Risse, Guenter B., Mending Bodies, Saving Souls: A History of Hospitals (New York/Oxford: Oxford University Press, 1999). Webster, Charles, Paracelsus: Medicine, Magic and Mission At the End of Time (New Haven, CT: Yale University Press, 2008).

chapter 12

h istory of m edici n e i n easter n eu rope , i nclu di ng russi a m arius t urda

Much has been done over the past three decades to strengthen the position of the history of European medicine among other academic disciplines. In addition to the continuous preoccupation with national medical traditions, topics such as international eugenics, health organizations, and transnational welfare movements have also benefited from sustained analysis. In comparison to the traditional medical historiography that is largely based on the narration of individual achievements in any particular country, the new direction of research suggests the need for a re-classification of medical thinking about society based on synchronized readings of concurrent medical traditions across countries and regions. The history of medicine—proponents of this new historiographic approach suggest—must be constantly renewed, whether this be its subject-matter or conceptual techniques in order to cope with the increased artistry of new methodologies and disciplines. Vibrant as this scholarship undoubtedly is, it does not compensate for one major weakness: its restricted geographical focus. With the exception of Russian and Soviet histories of medicine, Eastern Europe is rarely mentioned in general histories of international medicine.1 None of the books published in the prestigious Routledge Studies in the Social History of Medicine, for example, deal with Eastern Europe. The reasons for this neglect are numerous, including the ideological segregation existing during communism, the linguistic complexity of the region, and the persistence of outdated notions about the history of medicine itself. Even the internationalization of Eastern European academia that accompanied the political changes of the 1990s, which permitted its rapid adaptation to fresh historiographies and methodology, had, at least initially, only a modest impact on the various Eastern European histories of medicine. Sporadically, chapters dealing with Eastern European medicine have been published in edited volumes in the West,2 complementing the singular efforts of a handful of scholars who have repeatedly

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argued for the importance of Eastern Europe in understanding the wider European, as well as international, developments in the history of medicine.3 Nonetheless, a visible transformation of the scholarship started during the early twentieth-first century. Monographs and edited volumes published both in and about Eastern European countries now appear regularly, a trend not only driven by the emergence of a new generation of medical historians but, equally important, defining the crystallization of a new academic field in Eastern Europe, especially during the past decade.4 A number of factors contributed directly to this process, including improved access to archives, the re-publication of interwar medical texts, the influx of Western scholarship, and, most importantly, Eastern European scholars studying abroad. Opening the archives, for instance, led to a careful analysis of historical documents that sought to understand the ‘truth’ behind some of the twentieth century’s hitherto unapproachable topics, such as the participation of Eastern European physicians in the Holocaust. While these archival efforts have not necessarily resulted in the emergence of a conceptual consensus, supporters of this historiographic trend agreed on the crucial importance of the document itself for reconstructing the medical past. Other avenues of research, namely authors who insisted on a comparative reading of medical traditions, also materialized after 1990. Compared with the first category of studies, this latter historiographic approach attempted to resist the dogmatic reductionism of document analysis and to transcend national interests by initiating a particular style of historical writing, one that proposed an interdisciplinary methodology informed by a detached narration of historical facts. The existing Eastern European history of medicine combines these different styles of writing, aiming to be conceptually and thematically innovative as well as attentive to hitherto unresearched topics. There is an equally substantial effort being made to place medical thinking in the larger contexts of national and international politics and culture. In pursuit of its new identity, current historical scholarship in Russia and Eastern Europe not only brings together significant themes and developments in medicine as part of social history, political demography, and cultural anthropology, but also forcefully engages with some of the most central topics pertaining to the national traditions of these countries. And although there still is a conceptual divide between this new generation of historians of medicine and other historians, the hegemonic status of the latter is clearly being challenged. The aim of this chapter is to chart the broad contours of historical scholarship on medicine in Russia/Soviet Union and Eastern Europe. Whether dealing with practical developments or clusters of ideas, the history of medicine in Eastern European countries, as much as in Russia, shares certain narratives, conceptual traits, and methodological conventions. To this expository end, I shall be employing ‘Eastern Europe’ to refer to the former communist countries in Eastern Europe, in particular Poland, Czechoslovakia, Hungary, Romania, Yugoslavia, and Bulgaria. The comparative conceptual strategy proposed here, moreover, is intended not only to reveal much-needed research on neglected national case studies, but also to redefine wider debates in the history of medicine more generally. However, substantial research and analytical effort remains

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necessary to stimulate historiographic interest in these topics from a comparative perspective, at both regional and international levels.

History of medicine in Russia Medicine was an intrinsic component of the Soviet programme of nation-building from the beginning of the Bolshevik Revolution. The depressing hygienic conditions of the civilian population during and following the First World War unquestionably contributed to a new appreciation of medicine as a source of social activism and national mobilization. Additionally, the effects of the typhus epidemics were so severe that Lenin, in 1919, did not hesitate to declare that ‘either the louse conquers socialism or socialism conquers the louse’.5 Neither succeeded completely, but this statement is indicative of the social radicalism for which the Soviet project of creating a new society and individual would later become known. The most important manifestation of the Soviet approach to medicine was, therefore, to be found not merely in the establishment of medical institutions, but in the communist ideology itself. ‘This ideology’, as Mark G. Field remarked, ‘saw illness and (premature) mortality as primarily the product of a sick or pathological society, i.e. capitalism, to be brought under control first by socialism, and then by communism.’6 With the creation of the Commissariat of Health Protection in 1918, and then throughout the period of the New Economic Policy (1921–8), the Soviet regime set about challenging the validity of traditional Russian medicine, while criticizing the West for failing to understand the emerging ‘proletariat’ medicine. But this criticism was largely unjustified. Visiting the Soviet Union in the 1930s, the Swiss-American historian of medicine Henry E. Sigerist, for instance, stated unambiguously: I have come to the conclusion that what is being done in the Soviet Union today is the beginning of a new period in the history of medicine. All that has been achieved so far in five thousand years of medical history represents but a first epoch: the period of curative medicine. Now a new era, the period of preventive medicine, has begun in the Soviet Union.7

Other Western historians of medicine were, however, less inclined to eulogize Soviet medicine, preferring more critical evaluations instead. Following the pioneering studies published during the interwar period by Horsely Gantt, Arthur Newsholme, John A. Kingsbury, and Henry E. Sigerist,8 a more analytical scholarship emerged in the 1960s and 1970s, exemplified especially by the works of Mark G. Field, Loren R. Graham, and Kendall E. Bailles.9 During the 1980s and early 1990s, reflecting historiographic developments in Western European history of medicine, this scholarship diversified and new topics in Russian and Soviet medicine were proposed, including the professionalization of medicine, the history of public health, and social hygiene.10 Scholars like Nancy Frieden,11 Jeannete Tuve,12 John Hutchinson,13 and Susan Solomon,14 among others,

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persuasively demonstrated how ideas of health and hygiene were instrumental in the formation of Russian and Soviet medical cultures, cultures which, these authors argued, were the result of a number of factors, including the historical tradition of community medicine (zemstvo), the financial exigencies of the emerging Soviet state and political apparatus, and the environmentalist ideology of the Bolshevik leadership (the preeminence of nurture over nature in shaping the new ‘Soviet’ man and woman).15 What is more, this new scholarship described how Russian and then Soviet physicians made use of their expertise to promote both medical and social agendas; these physicians were, in fact, conditioned as much by the socio-political environment in which their ideas of social hygiene, public health, and preventive medicine were tested as they were by state mechanisms of power and control. As Susan Solomon has argued, with regard to the function social hygienists assumed during the 1920s, [t]he pivotal role of social hygiene in Soviet public health not only brought a new group of experts to prominence, it also broadened the scope and orientation of public health itself. In commissioning physicians to do research on issues of public health, the state medicalized a series of issues that had previously been treated as questions of law and order.16

Similarly, technical developments, such as those of the pharmaceutical industry, apart from qualifying as major medical achievements in their own right, were also—as Mary Schaeffer Conroy noted—the expression of a way of thinking about health that centred on the population and the ability of the Soviet state to sponsor scientific research and development, domestic production, distribution of medicine, and, of course, consumption of drugs.17 Following academia’s gradual liberalization during the Perestroika and afterward, other areas of research have attracted attention by sharing a vision of medical history as a dynamic ensemble of ideas, individuals, and state agencies rather than as merely a sum of physicians and medical institutions. These new topics include gender and the politics of reproduction, the transfer of scientific knowledge between Soviet Russia and other European countries, and eugenics. The scholarship on gender, reproduction, and natalist policies in the Soviet Union and post-Soviet Russia has been in ascendancy since the late 1970s, paralleling a more broad development in the humanities, which centred on new theories of sexuality and power elaborated by Michel Foucault and others. Accordingly, scholars such as Gail Lapidus, Wendy Goldman, Rosalind Marsh, Michele Rivkin-Fish, and Pat Simpson have shown how, in its attempts to create a socialist body politic, the communist state manipulated both medical discourses on health and national discourses on the family, thereby interweaving the reproduction of the social organism with the reproduction of the nation while simultaneously emphasizing women’s special role in this process of social engineering. The studies in this category are probably those that best accord with the idea that medicine under communism became an important locus for exercising state control and that medical knowledge lent scientific respectability to a variety of political and social projects.18

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Other scholars have attempted to sort out the complex relationship between politics and medicine by marshalling evidence from the experience of medical research in their international contexts and showing how this experience permeated the national spheres of hygiene and health. This interaction between the international and national dimensions of the history of medicine is a valuable addition to the growing body of scholarship on the transfer, appropriation, and rejection of scientific knowledge in modern cultures. Drawing on these premises, several edited volumes brought Russian and Western scholarship together, thus successfully overcoming the rather conventional political narratives of Soviet studies. Take the contributions by Mark B. Mirsky, Vladimir M. Verbitski, and Tatyana S. Sorokina, for example, included in a volume edited by John H. Cule and John M. Lancaster. These three Russian historians of medicine discussed state medicine in Russia until 1918, obstetrics and gynaecology in the nineteenth century, and state preventive measures and state intervention in the provision of health care during the Moscow plagues of 1771 and 1772, respectively.19 More recently, contributions by Russian historians of medicine have increased in an indication of the growing commitment to a new range of scholarly debates, such as the relationship between medicine and the Holocaust and the history of eugenics. In this sense, Boris Yudin, for example, provided a convincing account of the controversies surrounding the ethical issues of medical research and human experiments in Russia and the Soviet Union during the first decades of the twentieth century;20 Julia Gradskova, Elena Iarskaia-Smirnova, and Pavel Romanov engaged with issues of gender, social work, and child welfare;21 while Yulia V. Khen revealed less discussed features of Russian eugenics.22 These scholarly accomplishments are by no means isolated. Susan Gross Solomon’s 2006 edited volume, for example, offered fresh perspectives and original scholarship on a range of topics pertaining to Soviet–German collaboration in medicine and public health between the wars.23 Two of the contributions were by the Russian historians of medicine Marina Sorokina, who discussed the 200th anniversary of the Academy of Sciences of the USSR, and Nikolai Krementsov, who analysed the debate surrounding eugenics at the Seventh International Genetics Congress held in Edinburgh in 1939.24 Both considered collaborations between Russian and European scientists, German in particular, both at the personal level and a reflection of wider international developments and scientific trends. One corollary to the scholarship on international collaboration and transfer of knowledge is the history of eugenics and genetics.25 Krementsov, for instance, had established himself as a historian of science during Stalinism and Soviet genetics, more specifically.26 While Loren R. Graham had drawn attention to similar agendas shared by eugenics movements in Germany and Russia in the 1920s as early as the 1970s,27 it was only in the past two decades that the wider eugenic discourses were subjected to sustained analysis, most notably in the works of Mark B. Adams.28 The story of genetics in the Soviet Union, nevertheless, cannot be told in isolation from that of Lynsenkoism, the official Soviet science policy governing the work of geneticists in the USSR from about 1940 to 1960. The agriculturalist Trofim Lysenko (1898–1976) has attracted considerable attention from both Russian and Western scholars in the history of medicine.29 The ideological

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battle between Lysenko’s agrobiology (according to which environment predominated over heredity), proclaimed as ‘socialist biology’, and classical genetics began as early as 1936. This conflict impacted the evolution of medicine in both the Soviet Union and communist Eastern Europe, particularly after 1948. It was that year, at the meeting of the Lenin Pansoviet Academy of Agricultural Sciences in Moscow, that Lysenko was given the authority by the Soviety Communist Party to destroy the study of genetics throughout Eastern Europe. The legacy of this episode in the history of Eastern European medicine is still largely undocumented, but there are signs of scholarly improvement.30 With the collapse of communism during the 1990s, and the conversion of the Russian historians of medicine to non-Marxist interpretations of society and science, there is now a tendency to look anew at the medical heritages of the nineteenth and twentieth centuries. New contextual readings of these heritages, as those indicated above, show that the relationship between medicine, society, politics, and the state was much more complex than linear communist accounts had for decades suggested.31 This is an area in which there is still much work to be carried out. Similarly, as we shall see in the following section, many of the manifestations of this aggregated scholarship can be detected in the new history of medicine emerging in Eastern Europe after 1989. This is why to investigate it may prove rewarding, as its growing conceptual diversity—as in the case of Russia—invites us to rethink the existing geographical and cultural boundaries of the history of medicine. In turn, a more nuanced interpretation of the relationship between Eastern European medicine and its international context will certainly emerge once this context is properly documented, historically and scientifically.32

History of medicine in Eastern Europe Traditionally, studies on the history of medicine in Eastern Europe either have focused exclusively on the life and activities of important physicians—not surprisingly, perhaps, considering that in these countries history of medicine has been largely written by physicians33—or have ascribed to physicians their contribution to scientific knowledge in general.34 Most of the scholarship produced during communism, moreover, was largely contaminated by dogmatic Marxism, making it difficult to assess its intellectual value. In this, of course, historians of medicine were no different from other categories of historians.35 Confronting the difficult access to archives, one initial direction of research concentrated on the role played by the Rockefeller Foundation in establishing institutes of hygiene and public health in Eastern Europe between 1918 and 1940. Attempts were made by the victorious powers to establish a cordon sanitaire against communism and the resurgence of German imperialism following the First World War. Within this context, the Rockefeller Foundation offered an alternative vision of medical protection and financial support, one based on programmes of social hygiene and public health. The establishment of institutes of hygiene and public health during the interwar period was part of such programmes, in addition to offering training in modern methods of public

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health services to physicians and nurses. Numerous grants and fellowships, as well as direct financial contributions towards the costs of these new institutions, were being offered towards the creation of a group of professional experts who were to become— and many in fact did become—responsible for public health administrations in their native countries.36 Yet, in Eastern Europe, traditional medical practices and folk medicine, in addition to other methods employed by village healers, survived until the twentieth century. As scholars such as Aida Brenko, Željko Dugac, Mirjana Randić, and Mincho Georgiev have demonstrated with regard to the cases of Croatia and Bulgaria, at the beginning of the twentieth century traditional hygiene and healing were targeted by a new category of professionals educated in modern scientific medicine.37 Moreover, following the Peace Treaties of 1920–1, countries benefiting territorially in the ensuing peace treaties, like Romania and Yugoslavia, had to address regional disparities and the different institutional traditions in the newly annexed territories. These disparities existed, for instance, between the Romanian Old Kingdom and Serbia, which developed their health systems as independent nation-states, and Transylvania, Croatia, Bosnia, and Slovenia, which had been part of the Habsburg Empire prior to November 1918. In these circumstances, leading health reformers like the Croat Andrija Štampar (1888–1958), the Hungarian Béla Johan (1889–1983), and the Romanians Gheorghe Banu (1889–1957) and Iuliu Moldovan (1882–1966) played decisive roles in creating centralized systems for health and hygiene. Their conceptual approaches to nationalized hygiene and health systems became paramount in the interwar years when these doctors held important positions in the ministries of public health of Yugoslavia, Hungary, and Romania.38 Even after Štampar was forced to resign and took over as the leading expert for the Health Organization of the League of Nations, his ideas remained prominent and, as an instance of cross-border transfers, notably strong among Bulgarian experts on public health. The discursive contours of nationalism circulating within Eastern European medicine are also echoed in the eclectic historiography dealing with issues of gender and reproduction under communism. Initially most of this scholarship was produced by Western scholars,39 but recently gender studies and women’s history have benefited from intense local historical work, both strongly feminist and analytically comfortable with many subfields within the history of medicine. With the establishment of the journal Aspasia it seems that the hitherto largely absent Eastern European scholarly voices have finally found an appropriate forum for their social, cultural, and political interests. However, the geographical diversity and multiplicity of historical traditions in Eastern European medicine during the twentieth century are perhaps best addressed by international teams of scholars rather than individuals. An example of this tendency is Kurt Schilde and Dagmar Schulte’s edited volume on professional welfare in Eastern Europe.40 The editors successfully assorted micro with oral history techniques, providing a convincing portrait of various episodes in the history of social health in Eastern Europe. Contributions to this volume cover aspects relating to social policies, as well as its agents and achievemens in Hungary, Poland, Bulgaria, Croatia, the Soviet Union and Romania,

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Slovenia, and Latvia. Milena Angelova, for instance, provides an overview of the activities of the Society for the Fight against Tuberculosis in Bulgaria between 1908 and 1944, while Silvana Rachieru and Dorottya Szikra and Eszter Varsa engaged with some of the challenges faced by social workers in interwar Romania and the settlement movement in Budapest during the 1940s, respectively. This wide geographic distribution of topics adopted by the new scholarship is a positive development, but can also gave rise to problems of conceptual communication: different components of the social history of medicine arguably talking quite different languages, be it the topic of public health, epidemics, hygiene, social protectionism, or eugenics. Sabine Hering and Berteke Waaldijk addressed this epistemological conundrum in their volume on the history of welfare in Eastern Europe between 1900 and 1960.41 The publication of these edited volumes offers new perspectives on some hitherto neglected topics in the history of welfare, social hygiene, and public health. Complementing this collaborative endeavour is another geared towards unearthing and editing forgotten sources on the history of public health and the history of medicine more generally. Romanian historians of medicine, such as Valentin-Veron Toma, Octavian Buda, and the Hungarian Gábor Palló, are particularly active in this field.42 Others, like the Bulgarian Kristina Popova, have convincingly analysed the relationship between child welfare and national ideologies during the interwar period.43 Ideas about the health of the nation were also evident in the work of those interwar health reformers preoccupied with improving the hygienic conditions of the peasantry, as demonstrated by Judit Bíró’s 2006 collection of texts on rural public health in 1930s and 1940s Hungary.44 She included excerpts from seminal works such as László Kerbolt’s The Sick Village (1934) and Béla Johan’s Healing the Hungarian Village (1939). Both Kerbolt and Johan, director of the National Institute of Hygiene in Budapest, argued for improved national health policies and provided assessments of working conditions, poverty, and diseases in the Hungarian villages. Predominantly focused on rural environments, precarious hygiene conditions, malnutrition, social diseases (such as alcoholism), sexually transmitted diseases (syphilis, in particular), high levels of infant mortality, the rejection of modern medicine, and a persistence of traditional methods of healing, they all constituted determinant factors in shaping the emergence of policies of health and social hygiene in interwar Hungary. With the Rockefeller Foundation’s support, and under Johan’s supervision, public health demonstrations were organized in Hungarian villages during the late 1920s with the aim of familiarizing the rural population with modern hygiene methods, regular health screening, and preventive medicine.45 Bíró’s book, with its emphasis on the community and localism, also contributed to ongoing debates on the impact of state-controlled initiatives in public health and social hygiene on communities in rural parts of Eastern Europe during the interwar period. Central to medical theories developed by public health reformers about these regions was the idea that the biological condition of communities could also be improved with the help of external factors such as education and through a controlled environment to prevent and eradicate contagious diseases and parasites, as well as through sanitation and better housing.

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Another direction of research powerfully illustrates this process: Eastern Europem countries were and are religiously and ethnically heterogeneous so, not surprisingly, the idea of a homogeneous national community figured prominently in the dominant health discourses elaborated between 1900 and 1945. In these circumstances, health and hygiene became part of a larger eugenic and biopolitical agenda, serving as a vehicle for transmitting a social and political message that transcended political differences and opposing ideological camps. The idea of the healthy nation was as diverse ideologically as it was geographically: it was adhered to by professionals, scientists, and political elites irrespective of their different political and cultural camps. In stark contrast to the Soviet Union, eugenics in Eastern Europe has only recently been revived as an academic topic. When its existence was acknowledged by local historians of medicine, it was generally dismissed as insignificant. Gheorghe Brătescu, for example, described eugenics in Romania as ‘feeble’.46 Similarly, in the 1970s, the Hungarian historian of medicine Endre Réti examined Darwin’s influence on Hungarian medical thought in the first decades of the twentieth century, but marginalized the interest in eugenics of prominent Hungarian doctors. During the same period, Endre Czeizel, a historian of genetics, published several articles on the history of eugenics, but focused exclusively on the role played by Francis Galton and Karl Pearson in shaping the contours of the discipline, without mentioning the theoretical contributions made by Hungarian eugenicists.47 More recently, it was Maria Bucur who published the first book on an Eastern European eugenic movement, followed shortly by Magdalena Gawin’s history of Polish eugenics and Gergana Mirčeva’s discussion of Bulgarian eugenics.48 In Eastern Europe, eugenics—as Darko Polšek, Attila Melegh, and Marius Turda have argued—also had distinctive national overtones, differentiated by each country’s individual culture and social context. Exploring these specific permutations requires linguistic and analytical tools capable of capturing the multifarious nature of eugenic thinking. One must examine eugenic ideas and practices in their specific regional and national contexts on the one hand, while simultaneously integrating these phenomena into their international contexts on the other.49 A new generation of historians of eugenics credits comparative methodological models, instead of the conventional scholarship’s tendency to insist on the uniqueness of national cases, and suggest that the history of eugenics needs to be studied within a more integrative European and international framework. Rather than remaining mere appendices to specific national traditions, the commonly suppressed histories of the theory and practice of eugenics in Eastern Europe must necessarily be disclosed and discussed within their national historic contexts, and as local permutations of a larger, international, eugenic movement in interwar Europe.50 This new trajectory now includes such thorny topics as eugenic sterilization or the treatment of mental patients during the Second World War, both of which are only very recently touched upon by historians.51 Worth mentioning in this context are Brigitta Baran and Gábor Gazdag, who focused on the scientific debates that led Hungarian psychiatrists like Károly Schaffer (1864–1939) and László Benedek (1887–1945) to engage in eugenic activities during the 1930s; they also revealed how some of these activities influenced public health policies and the treatment of mental patients during the Second

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World War. Equally important is their treatment of Schaffer and his school within the general development of European psychiatry during the first half of the twentieth century.52 This recourse to historical memory is essential if, on the one hand, these countries are to be reconciled with their troubled past and if, on the other, the history of interwar eugenic movements is to be systematically analysed through their appropriate local, regional, national, and international contexts.

Conclusion The time has finally come for the history of medicine in Russia and Eastern Europe to be firmly situated within the international arena. To be sure, there is room for improvement, especially in terms of methodology and access to archival repositories. Above all, it is imperative that works of comprehensive synthesis are produced, studies that move away from narrow definitions of medical history and are theoretically and analytically of genuine sophistication. As late as 1993, Ludmilla Jordanova pondered whether the social history of medicine had achieved intellectual respectability as an academic discipline. As she understood it, for this to happen the discipline needed, first, to be based on ‘a wide range of primary sources known to active scholars, and a significant proportion of these should be in the public domain, that is, highly accessible, if possible published in some form’. Second, Jordanova continued, the social history of medicine ‘needs a basic map for the purpose of intellectual navigation. However contentious such a map may be, it provides the essential structure within which narratives are constructed, chronologies elaborated and frameworks refined.’ Other conditions required were ‘a secondary literature’ that ‘is both sufficiently diverse and sufficiently large to act as a critical mass’; and, finally, ‘a mature field conducts sophisticated debates, which encourage interpretations to be refined and, if necessary, radically altered’.53 Though some nuances are surely missing from this description, what Jordanova is arguing for—correctly I believe—is the meticulous exploration of the interaction between medical texts and their social, cultural, economic, and political contexts. Nowhere is this intellectual programme more important than in Russia and Eastern Europe. The history of medicine evolves on composite grounds: it reflects and is affected by historical circumstances, both diachronically and synchronically. Besides the task of mediating between the local canons in Russia and Eastern Europe and their international framework, there is a pressing need to tackle these phenomena in the framework of the entangled history within these regions: namely, to look at national medical traditions from a regional and cross-national perspective, and to thereby challenge the purported uniqueness and mimetic competition of these national cultures. History of medicine’s importance to the general historiographic traditions in these regions is yet to be acknowledged,54 but the fact that an increasing number of historians in Russia and Eastern Europe are interested in the history of eugenics, medical anthropology, psychiatry, and criminal anthropology is already noticeable.

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Compared with the pre-1989 period, this emerging scholarship claims not to be vitiated by ideological manipulation and biased interpretations. It remains, however, to be seen whether these new intellectual projects would have the desired impact on the discipline of history, in general, and the history of medicine in particular. Current debates and contestations accruing around the meaning of national history in Russia and Eastern Europe are an eloquent example that scholars in these regions are finally able to produce different, almost competing, readings of the past. The history of medicine, too, is currently undergoing a remarkable transformation—one defined by society’s need to engage with scientific advances and the ethical dilemmas they raise, on the one hand, and the inclusion of hitherto marginalized case studies on the other. The inclusion and juxtaposition of Russian and Eastern European histories of medicine with their well-known Western European counterparts thus lies at the heart of a more ambitious historiographic project that strives not only to yield original and timely archival research on these neglected national case studies, but also to redefine and diversify the overarching debate on the centrality of medicine in modern European history.

Notes 1. This is not to say that informative accounts of Eastern Europe medicine and health have not been produced by Western scholars, especially during the 1960s and 1970s, when reliable data were still available. Such studies include E. Richard Weinerman, Social Medicine in Eastern Europe: The Organization of Health Services and the Education of Medical Personnel in Czechoslovakia, Hungary, and Poland (Cambridge, MA: Harvard University Press, 1969); Michael Kaser, Health Care in the Soviet Union and Eastern Europe (London: Croom Helm, 1976); Michael Ryan, The Organization of Soviet Medical Care (Oxford: Blackwell, 1978); Gordon Hyde, The Soviet Health System: A Historical and Comparative Study (London: Lawrence and Wishart, 1974); and William A. Knaus, Inside Russian Medicine: An American Doctor’s First Hand Report (New York: Everest House, 1981). 2. Chapters on Russia, Poland, and the Czech Republic are included in William C. Cockerham (ed.), The Blackwell Companion to Medical Sociology (Oxford: Blackwell, 2001); on Czechoslovakia and Croatia in Iris Borowy and Wolf D. Gruner (eds), Facing Illness in Troubled Times: Health in Europe in the Interwar Years, 1918–1939 (Bern: Peter Lang, 2005); and on Hungary and Croatia in Iris Borowy and Anne Hardy (eds), Of Medicine and Men: Biographies and Ideas in European Social Medicine between the World Wars (Bern: Peter Lang, 2008). 3. Paul J. Weindling, Epidemics and Genocide in Eastern Europe (Oxford: Oxford University Press, 2000); Patrick Zylberman, ‘Mosquitos and the Komitadjis: Malaria and Borders in Macedonia (1919–1938)’, in Borowy and Gruner (eds), Facing Illness in Troubled Times, 305–43; Lion Murard and Patrick Zylberman, ‘French Social Medicine on the International Public Health Map in the 1930s’, in Esteban Rodríguez-Ocaña (ed.), The Politics of the Healthy Life: An International Perspective (Sheffield: European Association for the History of Medicine and Health Publications, 2002), 197–218.

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4. Petr Svobodný and Ludmila Hlaváčková, Dějiny lékařství v českých zemích (Prague: Triton, 2004); Károly Kapronczay and Katalin Kapronczay (eds), Az orvostörténelem Magyarországon (Budapest: Semmelweis Orvostörténeti Múzeum, 2005); and Radu Iftimovici, Istoria universală a medicinii şi farmaciei (Bucharest: Editura Academiei Române, 2008). 5. Quoted in Mark G. Field, ‘Soviet Medicine’, in Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000), 51–66, at 52. 6. Ibid. 7. Henry E. Sigerist, Socialized Medicine in the Soviet Union (New York: Norton, 1937), 308. 8. Horsley W. Gantt, A Medical Review of Soviet Russia (London: British Medical Association, 1928); Arthur Newsholme and John A. Kingsbury, Red Medicine: Socialized Health in Soviet Russia (Garden City, NY: Doubleday, 1933); Sigerist, Socialized Medicine in the Soviet Union; idem, Medicine and Health in the Soviet Union (New York: Citadel Press, 1947). 9. Mark G. Field, Doctor and Patient in Soviet Russia (Cambridge, MA: Harvard University Press, 1957); idem, Soviet Socialized Medicine: An Introduction (New York: Free Press, 1967); Loren R. Graham, Science and Philosophy in the Soviet Union (New York: Alfred Knopf, 1972); idem, Between Science and Values (New York: Columbia University Press, 1983); Kendall E. Bailes, Technology and Society under Lenin and Stalin: Origins of the Soviet Technical Intelligentsia, 1917–1941 (Princeton: Princeton University Press, 1978). 10. Mark G. Field, ‘The Hybrid Profession: Soviet Medicine’, in Anthony Jones (ed.), Professions and the State: Expertise and Autonomy in the Soviet Union and Eastern Europe (Philadelphia: Temple University Press, 1991), 43–62. 11. Nancy M. Frieden, Russian Physicians in an Era of Reform and Revolution, 1856–1905 (Princeton: Princeton University Press, 1981). 12. Jeanette E. Tuve, The First Russian Women Physicians (Newtonville, MA: Oriental Research Partners, 1984). 13. John F. Hutchinson, Politics and Public Health in Revolutionary Russia, 1890–1918 (Baltimore: Johns Hopkins University Press, 1990). 14. Susan Solomon and John F. Hutchinson (eds), Health and Society in Revolutionary Russia (Bloomington: Indiana University Press, 1990). 15. Amir Weiner, ‘Nature, Nurture, and Memory in a Socialist Utopia: Delineating the Soviet Socio-Ethnic Body in the Age of Socialism’, American Historical Review 104 (4) (1999), 1114–55. See also Mark B. Adams, ‘The Soviet Nature-Nurture Debate’, in Loren R. Graham (ed.), Science and the Soviet Social Order (Cambridge, MA: Harvard University Press, 1990), 94–138; Daniel Beer, Renovating Russia: The Human Sciences and the Fate of Liberal Modernity, 1880–1930 (Ithaca: Cornell University Press, 2008). 16. Susan Gross Solomon, ‘The Expert and the State in Russian Public Health: Continuities and Change across the Revolutionary Divide’, in Dorothy Porter (ed.), The History of Public Health and the Modern State (Amsterdam: Rodopi, 1994), 183–223, at 185. 17. Mary Schaffer Conroy, The Soviet Pharmaceutical Business during Its First Two Decades, 1917–1937 (New York: Peter Lang, 2006). 18. Gail Lapidus, Women in Soviet Society (Berkeley: University of California Press, 1978); Wendy Goldman, Women, the State and the Revolution: Soviet Family Policy and Social Life, 1917–1936 (Cambridge: Cambridge University Press, 1993); and the contributions by Janet Hyer, Susan Gross Solomon, and Christopher Williams in Rosalind J. Marsh (ed.), Women in Russia and Ukraine (Cambridge: Cambridge University Press, 1996); Michele Rivkin-Fish, Women’s Health in Post-Soviet Russia: The Politics of Intervention (Bloomington: Indiana University Press, 2005); Pat Simpson, ‘Bolshevism and “Sexual revolution”:

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19.

20.

21.

22. 23. 24.

25. 26.

27. 28.

29.

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Visualising New Soviet Woman as an Eugenic Ideal 1917–1932’, in Fae Brauer and Anthea Callen (eds), Corpus Delecti: Art, Sex and Eugenics (Aldershot: Ashgate, 2008), 209–38. Mark B. Mirsky, ‘State of Medicine in Russia (1581–1918)’, in John H. Cule and John M. Lancaster (eds), Russia and Wales: Essays on the History of State Involvement in Health Care (Cardiff: History of Medicine Society of Wales, 1994), 15–29; Vladimir M. Verbitski, ‘Ethical Problems in Nineteenth Century Russian Clinical Medicine Relating to Obstetrics and Gynaecology’, ibid. 31–42; and Tatyana S. Sorokina, ‘The Struggle against the Plague Moscow, 1771–1772’, ibid. 43–65. Boris Yudin, ‘Human Experimentation in Russia/Soviet Union in the First Half of the 20th Century’, in Volker Roelcke and Giovanni Maio (eds), Twentieth Century Ethics of Human Research: Historical Perspectives on Values, Practices, and Regulations (Stuttgart: Franz Steiner Verlag, 2004), 99–110. Julia Gradskova, ‘ “Nurseries Have Brought up Children”: Maternity, Gender and Social Work in the Soviet Union in the 1930s to the 1950s’, in Kurt Schilde and Dagmar Schulte (eds), Need and Care: Glimpses into the Beginning of Eastern Europe’s Professional Welfare (Opladen: Barbara Budrich, 2005), 75–90; Elena Iarskaia-Smirnova and Pavel Romanov, ‘Institutional Child Care in Soviet Russia: Everyday Life in the Children’s Home “Krasnyi Gorodok” in Saratov, 1920s–1940s’, ibid. 91–121. Yulia V. Khen, ‘Unknown Pages of Russian Eugenics’, Herald of the Russian Academy of Sciences 76 (4) (2006), 385–91. Susan Gross Solomon (ed.), Doing Medicine Together: Germany and Russia between the Wars (Toronto: University of Toronto Press, 2006). Marina Sorokina, ‘Partners of Choice/Faute de Mieux? Russians and Germans at the 200th Anniversary of the Academy of Sciences, 1925’, in Solomon (ed.), Doing Medicine Together, 61–102; Nikolai Krementsov, ‘Eugenics, Rassenhygiene, and Human Genetics in the Late 1930: The Case of the Seventh International Genetics Congress’, ibid. 368–404. For a Soviet perspective, see A. E. Gaissinovitch, ‘The Origins of Soviet Genetics and the Struggle with Lamarckism, 1922–1929’, Journal of the History of Biology 13 (1) (1980), 1–51. Nikolai Krementsov, Stalinist Science (Princeton: Princeton University Press, 1997); idem, International Science between the World Wars: The Case of Genetics (London: Routledge, 2005). Loren R. Graham, ‘Science and Values: The Eugenics Movement in Germany’, American Historical Review 82 (5) (1977), 1133–64. Mark B. Adams, ‘Eugenics in Russia, 1900–1940’, in idem (ed.), The Wellborn Science: Eugenics in Germany, France, Brazil, and Russia (Oxford: Oxford University Press, 1990), 153–216; idem, ‘Eugenics as Social Medicine in Revolutionary Russia’, in Solomon and Hutchinson (eds), Health and Society in Revolutionary Russia, 200–23; Alberto Spektorowski, ‘The Eugenic Temptation in Socialism: Sweden, Germany, and the Soviet Union’, Comparative Studies in Society and History 46 (2004), 84–106; Mark B. Adams, Garland E. Allen, and Sheila Faith Weiss, ‘Human Heredity and Politics: A Comparative Institutional Study of the Eugenics Record Office at Cold Spring Harbor (United States), the Kaiser Wilhelm Institute for Anthropology, Human Heredity, and Eugenics (Germany), and the Maxim Gorky Medical Genetics Institute (USSR)’, Osiris 20 (2005), 232–62. Valery N. Soyfer, Lysenko and the Tragedy of Soviet Science (New Brunswick, NJ: Rutgers University Press, 1994); Nils Roll-Hansen, The Lysenko Effect: The Politics of Science (Amherst, NY: Prometheus Books, 2004).

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30. William deJong-Lambert, ‘Szczepan Pieniążek, Edmund Malinowski, and Lysenkoism in Poland’, East European Politics and Societies 21 (3) (2007), 403–23; and William deJongLambert, ‘The New Biology in Poland after the Second World War: Polish Lysenkoism’, Paedagogica Historica 45 (2009), 403–20; Miklós Müller, ‘Lysenkoism in Hungary’, paper presented at the International Workshop on Lysenkoism, Harriman Institute, Columbia University, New York, 4–5 December 2009. 31. Irina Sirotkina, Diagnosing Literary Genius: A Cultural History of Psychiatry in Russia, 1880–1930 (Baltimore: Johns Hopkins University Press, 2002). 32. Marius Turda, ‘Focus on Social History of Medicine in Central and Eastern Europe’, Social History of Medicine 21 (2008), 395–401; Marius Turda and Paul J. Weindling, ‘Eugenics, Race and Nation in Central and Southeast Europe, 1900–1940: A Historiographic Overview’, in Marius Turda and Paul J. Weindling (eds), Blood and Homeland: Eugenics and Racial Nationalism in Central and Southeast Europe, 1900–1940 (Budapest: Central European University Press, 2007), 1–20; and Marius Turda et. al., ‘Framing Issues of Health, Hygiene and Eugenics in Southeastern Europe’, in Christian Promitzer et. al. (eds), Health, Hygiene and Eugenics in Southeastern Europe to 1945 (Budapest: Central European University, 2011), 1–24. 33. Gh. Bratescu and Klaus Fabritius, Biological and Medical Sciences in Romania (Bucharest: Editura Ştiinţificǎ şi Enciclopedicǎ, 1989; Lazar Stanojević (ed.), 700 godina medicine u Srba—700 ans de médecine chez lez Serbes (Belgrade: Srpska akademija nauka i umetnosti, 1971); Izet Mašić, Korijeni medicine i zdravstva u Bosni i Hercegovini (Sarajevo: Avicena, 2005); and Győző Birtalan, Évszázadok orvosai (Budapest: Akadémiai Kiadó, 1995). One should also mention here journals like La Santé Publique, Archives de l’Union Médicale Balkanique (published in Bucharest), and Orvostörténeti Közlemények (published in Budapest), which commissioned and published numerous articles written by physicians on the history of medicine from all communist countries. 34. The Croat health reformer Andrija Štampar is arguably the most known case. See M. D. Grmek (ed.), Serving the Cause of Public Health: Selected Papers of Andrija Štampar (Zagreb: Skola narodnog zdravlja Andrija Štampar, 1966); and Željko Dugac, ‘New Public Health for a New State: Interwar Public Health in the Kingdom of Serbs, Croats, and Slovenes and the Rockefeller Foundation’, in Borowy and Gruner (eds), Facing Illness in Troubled Times, 277–304. 35. There are of course exceptions in each country. For Romania, see Valeriu L. Bologa, Din istoria medicinii româneşti şi universale (Bucharest: Editura Academiei Republicii Populare Române, 1962). 36. For Hungary, see Gábor Palló, ‘Make a Peak on the Plain: The Rockefeller Foundation’s Szeged Project’, in William H. Schneider (ed.), Rockefeller Philanthropy and Modern Biomedicine: International Initiatives from World War I to the Cold War (Bloomington: Indiana University Press, 2002), 87–105; for Romania, see Ecaterina Petrina, The Impact of the Rockefeller Foundation on Romanian Scientific Development, 1920–1939, PhD dissertation, Cornell University, 1997; for Yugoslavia, see Željko Dugač, Protiv bolesti i neznanja: Rockefellerova fondacija u međuratnoj Jugoslaviji (Zagreb: Srednja Europa, 2005); for Bulgaria, see Milena Angelova, ‘Rokfelerovata fondatsiya i amerikanskata blizkoiztochna fondatsiya v Balgariya—initsiativi v poleto na sotsialnata rabota, 20–30te godini na XX vek’, in Kristina Popova and Milena Angelova (eds), Obshtestveno podpomagane i sotsialna rabota v Balgariya: Istoriya, institutsii, ideologii, imena (Blagoevgrad: Yugozapaden universitet ‘Neofit Rilski’ Blagoevgrad, 2005), 112–25.

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37. Aida Brenko, Željko Dugac, and Mirjana Randić, Narodna medicina (Zagreb: Etnografski muzej Zagreb, 2001); Mincho Georgiev (ed.), Balgarska narodna medicina. Enciklopediya (Sofia: Izdatelska kashta ‘Petar Beron’, 1999). 38. Henry E. Sigerist, ‘Yugoslavia and the XIth International Congress of the History of Medicine’, Bulletin of the History of Medicine 7 (1939), 99–147. 39. Alena Heitlinger, Reproduction, Medicine and the Socialist State (London: Macmillan, 1987); Nanette Funk and Magda Mueller (eds), Gender Politics and Post Communism: Reflections from Eastern Europe and the Former Soviet Union (New York: Routledge, 1993); Henry P. David (ed.), From Abortion to Contraception: A Resource to Public Policies and Reproductive Behaviour in Central and Eastern Europe from 1917 to the Present (Westport, CT: Greenwood Press, 1999); Susan Gal and Gail Kligman (eds), Reproducing Gender: Politics, Publics, and Everyday Life after Socialism (Princeton: Princeton University Press, 2000). 40. Kurt Schilde and Dagmar Schulte (eds), Need and Care: Glimpses into the Beginnings of Eastern Europe’s Professional Welfare (Opladen: Barbara Budrich, 2005). 41. Sabine Hering and Berteke Waaldijk, Guardians of the Poor: Custodians of the Public. Welfare History in Eastern Europe, 1900–1960 (Opladen: Barbara Budrich, 2006). 42. Valentin Veron-Toma and Adrian Majuru (eds), Nebunia. O antropologie istorică românească (Bucharest: Paralela 45, 2006); Octavian Buda, Criminalitatea. O istorie medico-legală românească (Bucharest: Paralela 45, 2007); Valentin Veron Toma, Alexandru Sutzu: Începuturile psihiatriei ştiinţifice în România secolului al XIX-lea (Bucharest: Dowiner, 2008); and Octavian Buda (ed.), Despre regenerarea şi degenerarea unei naţiuni (Bucharest: Tritonic, 2009). 43. Kristina Popova, Natsionalnoto dete. Blagotvoritelnata i prosvetna deynost na Sajuza za zakrila na detsata v Balgariya 1925–1944 (Sofia: LIK, 1999). 44. Judit Bíró (ed.), Hivatalos falukutatók: A vidéki Magyarország leírása 1930 és 1940 között (Budapest: Polgart, 2006). 45. Gábor Palló, ‘Rescue and Cordon Sanitaire: The Rockefeller Foundation in Hungarian Public Health’, Studies in History and Philosophy of Biological and Biomedical Sciences 31 (2000), 433–45. 46. Gh. Brătescu, Către sănătatea perfectă: O istorie a utopianismului medical (Bucharest: Humanitas, 1999), 406–11. 47. Endre Réti, ‘Darwin’s Influence on Hungarian Medical Thought’, Medical History in Hungary (Budapest, 1972), 157–67; Endre Czeizel, ‘A biométerek és a mendelisták ellentéte’, Orvosi Hetilap 113, 4 (1972), 213–17; Endre Czeizel,‘Az eugenika—létrejotte, kompromittálása és jövője’, Orvosi Hetilap 113 (6) (1972), 331–4; Ferenc Pisztora, ‘Benedek László élete, személyisége és életművének társadalom- és kultúrpsychiátriai, psychologiai és eugenikai vonatkozásai’, Ideggyógyászati Szemle 41 (1988), 441–56. 48. Maria Bucur, Eugenics and Modernization in Interwar Romania (Pittsburgh: Pittsburgh University Press, 2000); Magdalena Gawin, Rasa i nowoczesność. Historia polskiego ruchu eugenicznego, 1880–1952 (Warsawa: Wydawnicwo Neriton, 2003); Gergana Mirčeva, ‘Balgarskiyat evgenichen proekt ot 20-te i 30-te godini na minaliya vek i normativniyat kod na ‘rodnoto’, Kritika i humanizam 17 (1) (2004), 207–21. See also Marius Turda, ‘The Nation as Object: Race, Blood and Biopolitics in Interwar Romania’, Slavic Review 66 (3) (2007), 413–41; and Ilija Malović, ‘Eugenika kao ideološki sastojak fašizma u Srbiji 1930-ih godina XX veka’, Sociologija 50 (1) (2008), 79–96. 49. Darko Polšek, Sudbina odabranih: Eugenička nasljede u urijeme genske tehnologije (Zagreb: ArTresor, 2004); Attila Melegh, On the East-West Slope: Globalization,

history of medicine in eastern europe, including russia

50.

51.

52.

53. 54.

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Nationalism, Racism and Discourses on Central and Eastern Europe (Budapest: Central European University Press, 2006); Marius Turda and Paul J. Weindling (eds), Blood and Homeland: Eugenics and Racial Nationalism in Central and Southeast Europe, 1900–1940 (Budapest: Central European University Press, 2007); Christian Promitzer et al. (eds), Health, Hygiene, and Eugenics in Southeastern Europe to 1945; and Marius Turda, Modernism and Eugenics (Basingstoke: Palgrave Macmillan, 2010). Marius Turda, ‘ “A New Religion”: Eugenics and Racial Scientism in Pre-World War Hungary’, Totalitarian Movements and Political Religions 7 (3) (2006), 303–25; Marius Turda,‘Heredity and Eugenic Thought in Early Twentieth-Century Hungary’, Orvostörténeti Közlemények. Communicationes de Historia Artis Medicinae 52 (1–2) (2006), 101–18; and idem, ‘The Biology of War: Eugenics in Hungary, 1914–1918’, Austrian History Yearbook 40 (1) (2009), 238–64. Marius Turda, ‘ “To End the Degeneration of a Nation”: Debates on Eugenic Sterilization in Interwar Romania’, Medical History 53 (1) (2009), 77–104; Béla Siró,‘Eugenikai törekvések az ideg- és elmegyógyászatban Magyarországon a két világháború között’, Orvosi Hetilap 144 (35) (2003), 1737–42; Magdalena Gawin, ‘Polish Psychiatrists and Eugenic Sterilization during the Interwar Period’, International Journal of Mental Health 36 (1) (2007), 67–78; and Kamila Uzarczyk, ‘War against the Unfit: Eugenic Sterilization in German Silesia, 1934–1944: Sine Ira et Studio (without Anger and Bias)’, International Journal of Mental Health 36 (1) (2007), 79–88. For the treatment of mental patients during the Second World War, see Vasyl Doguzov and Svitlana Rusalovs’ka, ‘The Massacre of Mental Patients in Ukraine, 1941–1943’, International Journal of Mental Health 36 (1) (2007), 105–11. Brigitta Baran and Gábor Gazdag, ‘The Fate of the Hungarian Psychiatric Patients during World War II’, International Journal of Mental Health 35 (4) (2006–7), 88–99; and Brigitta Baran, István Bitter, Max Fink, Gábor Gazdag, and Edward Shorter, ‘Károly Schaffer and His School: The Birth of Biological Psychiatry in Hungary, 1890–1940’, European Psychiatry 23 (6) (2008), 449–56. Ludmilla Jordanova, ‘Has the Social History of Medicine Come of Age?’, Historical Journal 36 (2) (1993), 437–49, at 437. For example, the most recent evaluation of Hungarian historiography does not even mention the contributions made by historians of medicine. See Gábor Gyáni, ‘Trends in Contemporary Hungarian Historical Scholarship’, Social History 34 (2) (2009), 250–60.

Select Bibliography Borowy, Iris, and Wolf D. Gruner (eds), Facing Illness in Troubled Times: Health in Europe in the Interwar Years, 1918–1939 (Bern: Peter Lang, 2005). ——— , and Anne Hardy (eds), Of Medicine and Men: Biographies and Ideas in European Social Medicine between the World Wars (Bern: Peter Lang, 2008). Bynum, W. F., and Roy Porter (eds), Companion Encyclopedia of the History of Medicine, 2 vols (London: Routledge, 1993). Cooter, Roger, and John Pickstone (eds), Medicine in the Twentieth Century (London: Routledge, 2000). Farley, John, To Cast Out Disease: A History of the International Health Division of the Rockefeller Foundation (1913–1951) (Oxford: Oxford University Press, 2003).

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Porter, Roy (ed.), The Cambridge History of Medicine (Cambridge: Cambridge University Press, 2006). Promitzer, Christian, Sevasti Trubeta, and Marius Turda (eds), Health, Hygiene, and Eugenics in Southeastern Europe to 1945 (Budapest: Central European University Press, 2011). Rodríguez-Ocaña, Esteban (ed.), The Politics of the Healthy Life: An International Perspective (Sheffield: EAHMHP, 2002). Solomon, Susan Gross (ed.), Doing Medicine Together: Germany and Russia between the Wars (Toronto: University of Toronto Press, 2006). ——— , Lion Murard, and Patrick Zylberman (eds), Shifting Boundaries of Public Health: Europe in the Twentieth Century (Rochester, NY: University of Rochester Press, 2008). Turda, Marius, Modernism and Eugenics (Basingstoke: Palgrave Macmillan, 2010). ——— , and Paul J. Weindling (eds), Blood and Homeland: Eugenics and Racial Nationalism in Central and Southeast Europe, 1900–1940 (Budapest: Central European University Press, 1997). Weindling, Paul (ed.), International Health Organisations and Movements, 1918–1939 (Cambridge: Cambridge University Press, 1995). Woodward, John, and Robert Jütte (eds), Coping with Sickness: Perspectives on Health Care, Past and Present (Sheffield: EAHMHP, 1996).

chapter 13

sci e nce a n d m edici n e i n the u n ited state s of a m er ica e dmund r amsden

In the most celebrated of reflections on America, Alexis de Tocqueville (1805–59) expressed great optimism for its future as the embodiment of the democratic state. On his arrival in 1831, it seemed to him a society formed of all the peoples of the world, differing in language, belief, and character, yet forming a nation possessing ‘happiness a hundred times greater than our own’.1 What made this New World such an improvement on the Old? De Tocqueville saw in the United States a propitious combination of population and place—of the coming together of refined European values and traditions in a world of new possibilities. It was a land that was immense, fertile, and sparsely populated, allowing for freedom and independence. All seemed malleable and mobile as men were made and unmade, and landscapes transformed. America gifted de Tocqueville the opportunity to express his liberal political ideals, arguing that its success was based on a community of common sensibility—that of personal interest, over and above that of the state. However, he also appended to his celebration of America a warning for its future. De Tocqueville saw the Americans as neglectful of the higher sciences, art, and literature. This resulted from a dedication to industry and trade and an ability to attract great minds from Europe.2 However, perhaps more significantly, he expressed concern at the oppressive treatment of certain populations by the State. The freedoms extended to white populations in a federal system, allowing them to establish their own towns, cities, and laws, had not been extended to all. While African-Americans faced poverty and ill-health due to the poor environments in which they lived, Native Americans faced utter extermination. While de Tocqueville was concerned with political systems and economies—sickness, health, and science getting only a passing mention—we can see many of his concerns reflected in the future work of historians of medicine. When Henry Sigerist described

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his first visit to America in 1932, he similarly wrote of his excitement at the immensity of the landscape, the heterogeneity of its peoples, and his optimism with regard to its future: ‘Never before had I felt so clearly that I was envisaging history in the making.’3 He observed how a nation that was once a medical backwater, dependent upon Europe for its ideas and education, was rapidly becoming a dominant force in world medicine. He sought explanations for this transformation. Yet he also expressed concern. While he may not have shared de Tocqueville’s politics, Sigerist also identified the failure to secure the health and well-being of the population in its entirety, noting the significant inequalities in access to quality health care.4 Sigerist’s history of medicine was socially embedded, grounded in the social and economic realities of contemporary society. Medicine offered a window onto American life, past, present, and future. In turn, an understanding of society and politics endowed the historian with the power to help remake health care.5 For Sigerist and the many historians of medicine that have followed, the tensions, contradictions, conflicts, and speed of change in American society make it a particularly rich site for tracing the shifting meanings of sickness and methods of prevention and cure. Focusing on the fundamental elements of population and place, we have a nation that is diverse in terms of its peoples, cultures, and geography, allowing us to explore and compare the ways in which medicine is developed and applied in a number of different social, cultural, and physical contexts. We also have rapid growth, from a period in which European ideas, methods, and structures—British, French, and German—were adapted to the American context, to one in which the United States is at the forefront of large-scale initiatives in public health, disease control, and innovation in the biomedical sciences. And finally we have contradiction, most notably between profound faith in the technical capacities of medical science and equally profound dissatisfaction with the provision of health care.6 The result is a nation particularly well suited for comparative analyses of health and medicine across peoples, place, and time.

The identity and character of early American medicine, health, and disease The arrival of Europeans in the Americas brought diseases that decimated Native American populations. Colin Calloway describes a ‘biological nightmare’,7 and Russell Thornton a ‘holocaust’,8 as families, even entire tribes, were destroyed by smallpox, measles, plague, cholera, influenza, typhus, and yellow fever. These were illnesses against which native populations had no immunological resistance, having escaped the great epidemics of Europe and Asia. While now well known, it was not until the careful historical work of those such as Henry Dobyns that the demographic scale and historical significance of the devastation was fully appreciated.9 While the North American continent has often been described as an empty wilderness or virgin land open to settlement

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by the European, it was, in effect, ‘widowed’.10 North America was relatively densely populated in 1492, with a population of somewhere between 5 to 10 million. By 1800, this had dwindled to a mere 600,000—a ‘demographic disaster’ that enabled its conquest by Europeans.11 The first European settlements also suffered disease, Virginia being described as a death-trap for colonists.12 However, by the time of independence, Americans were celebrating the health of their nation’s citizens, free as they were from the plagues of illness that swept across Europe. A nation’s strength was to be measured in the health and vitality of its peoples, and for Benjamin Franklin (1706–90), independence had been inevitable—the reflection of the rapid population growth of America in contrast to that of Britain.13 Such self-congratulation proved short-lived, as ill-health came to be reflected in the decline in stature of its peoples from the time of the American Revolution.14 The problem of the American city loomed large in the minds of social reformers and physicians, earlier concerns with yellow fever and smallpox being replaced by the dread of cholera.15 While concern with crowd diseases were also common in Europe and Asia, shifting trends in migration and the different climate and geography of the United States and its various regions meant the emergence of specific disease cultures and environments.16 Central to historical debates is the degree to which American medicine can be viewed as distinctive. Ronald Numbers suggests that an assumption of American exceptionalism has pervaded the literature. He notes how much has been made of the influence of the physical environment, the frontier culture, and the determination to eschew theory and specialization in favour of pragmatism and the general practitioner. The lack of distinction between physician and surgeon and the lack of a rigid medical aristocracy, for example, are seen to result from an American aversion to class distinction. This distinctiveness has been critically examined in a series of essays, edited by Numbers, focusing on New Spain, New France, and New England. While the authors accept that medicine was influenced by indigenous healers, there is also a consensus that American medical practices were directly related to older European traditions and ‘changed remarkably little in transit’.17 Certainly, when we explore the development of American medicine in the nineteenth century, we can see varying degrees of influence of Britain, France, and Germany. Yet American practitioners were also selective and, in the new setting, medicine was adapted and altered.18 In the first decades of the United States, therapeutic practices remained tied to traditional ideas of a balance or equilibrium of the body, demanding the physicians intervene through drugs or bloodletting.19 American medical education was modelled on that of Edinburgh: it had a similar two-tier system, the practitioner attending general classes for a matter of months and the highest honour of MD being the privilege of those that were able and could afford to study intensively in Latin for two years. Yet while the British medical college was regulated by guild and government, distrust of elites and monopolies and an interest in the wealth that an open and competitive educational system could generate resulted in a more fluid medical marketplace in the United States.20 The result was a proliferation of proprietary medical colleges that continued to reduce fees, requirements, and, thus, the standard of education

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and training. As a consequence, a variety of specialisms and alternatives to therapeutic activism could remain, emerge, and develop—optometry, chiropractics, osteopathy, psychology, and midwifery.21 This diversity and pluralism was only further reinforced with the growing influence of French medicine from the 1820s. Focusing on the professional interests of the physician, John Harley Warner argues that the turn away from rationalistic systems of practice towards clinical empiricism reflected fear and anxiety regarding the status of medicine in the United States.22 With growing public concern surrounding the effectiveness of traditional therapeutics, compounded by the lack of licensing and regulation that lowered standards and allowed for alternative medicine, it seemed that the privilege bestowed upon the American medical man was being eroded. Empiricism would help consolidate legitimacy, status, and authority. It demanded moderation and the physician’s ability to tailor treatment to take account of the specific characters of a patient— their age, race, gender, and occupation—as well as the social and physical environments in which they existed—climate, demography, and geography. Once again, this was no direct transfer from Europe to America, but the empiricist approach was wedded to a continued, if more muted, commitment to therapeutic activism. Warner was one of the first to use this focus on empiricism to turn the attention of the historian to the variety of medical practices across the United States. He observed that historians have tended to generalize the experience of the Northeast to the rest of America.23 With the questioning of universal rules of practice came a new emphasis on the local and new ideas about the differences between the medical needs and practices of African American and European, North, West, and South. The South has dominated the study of regional difference in American health and medicine—its climate and traditions of slavery and the plantation system having led to an historical tradition of Southern distinctiveness, almost a ‘nation within a nation’.24 While such environmentalist arguments have been disputed in history more generally, uniqueness is now being reclaimed through the case of disease. Malaria, yellow fever, and hookworm thrived in ‘a modified West African disease environment’.25 For Margaret Humphreys, the ongoing struggle with yellow fever, combined with rural poverty, meant that the objectives, attitudes, and achievements of southern public health officials were ‘strikingly different’ from their northern urban counterparts.26 The South also had different populations and social structures. Anthropometric histories have revealed the health of the slave population to be extremely poor,27 yet their resistance to yellow fever and malaria was used by apologists of slavery to emphasize the medical distinctiveness of the black body and its suitability to labouring in hot and humid environments.28 As Warner argues, this emphasis on the region’s medical peculiarity was not simply a reflection of racism, nationalism, and regional self-consciousness, but an attempt to promote the status of the Southern medical practitioner and compete with northern medical schools. More recently, the work of Sharla Fett has added a further layer of complexity by examining the distinctiveness of slave medicine—not only due to African and West Indian remedies, but as the result of attempts to confront the processes of

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dehumanization through community-building and self-determination.29 In turn, Todd Savitt has extended our understanding of black medicine after 1865. African Americans struggled to establish independent, and desperately needed, sources of medical education following emancipation. Nevertheless, most black-owned proprietary institutions failed due to a lack of funding, while the few successes remained dependent upon white philanthropy and organized medicine.30 With the eclipse of the French model in the period of German ascendancy after 1870, there took place a further standardization of medical school, hospital, and experimental laboratory, and numerous specialist societies emerged. The development of laboratorybased medical science and the training of physicians in Germany brought a significant improvement in medical education. New centres of excellence, such as Harvard Medical College and the Johns Hopkins School of Medicine, extended the length of degrees, demanded prior education, and became tied to the university.31 Yet, once again, there was no straightforward transfer from one place to another. Thomas Bonner argues that the mixed experiences of American students in Germany, the tradition of egalitarianism, coupled with the competition between medical schools, led to a particularly aggressive emphasis on laboratory instruction and clinical experience for all students. There was also a great deal of division and debate over what scientific medicine was, and how it was to be related to practice and made useful to the populace. Warner argues that the new experimental therapeutics based on physiological science divided physicians— some seeking to understand the laws and principles that governed health and illness, others seeking to retain an individualized therapeutics based upon clinical empirical observation.32 Indeed, this tension can be seen to endure in the (much under-studied) differences between population medicine—the epidemiological, statistical, and biometric methods that allow for the study of disease in nature—and clinical medicine— based upon the laboratory and focused on the individual patient.

The growth of American medicine: continuity and fragmentation Prior to World War I, Europe had imported students from the United States and exported medical experts, ideas, methods, and technologies. The world wars helped reverse this dependency.33 Reconstruction in Europe demanded new and more effective hospitals, medical schools, and agencies of public health. These were provided through the support of American organizations and would reflect their visions of medical science and practice. In turn, the critical role of science in war enhanced belief in the power of medicine to rid the world not only of infectious, but also of chronic, disease, thus significantly extending the quality and length of life. When Vannevar Bush presented to the President his vision of federally funded ‘big science’ in 1945, he began by extolling the ‘genius’ behind the new drug, penicillin.34

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As significant as the Public Health Service and its Laboratory of Hygiene was becoming, it grew slowly in the first half of the twentieth century.35 With governmental finances severely restricted, much of the progress in medicine was supported by another largely American innovation—the philanthropic foundation. Their workings and influence have been subject to increasing historical analysis, the Rockefeller Foundation receiving the most attention.36 A child of the Progressive Era, when medicine and sanitation were promoted as a means to national unity, order, and efficiency, Rockefeller philanthropy first turned its attention to the South.37 From 1909, the Rockefeller Sanitary Commission for the Eradication of Hookworm combined scientific medicine and public health education—identifying the real causes of the disease, strengthening the dilapidated Southern boards of health, and using health demonstrations to promote preventative health behaviour and services.38 While the aims of the Sanitary Commission have been associated with benevolent sanitary and health reform that broke down boundaries between North and South, urban and rural, private wealth and public agencies,39 historians also see it driven by economic interest. That Rockefeller philanthropy soon applied its methods honed in the South to global populations reinforces this perspective. Many see the International Health Division as having promoted a capitalist, even colonial, medicine that commodified health, promoted technological solutions over prevention, economic gain over social equality, and generated medical dependency.40 More recently, however, a more nuanced historical approach has emerged, focused on the complex, disparate, and often competing interests of foundation officials and local actors.41 While the actions of foundations were often limited and fragmented by continuous negotiation between its members, their structure also gave them certain advantages.42 They could act and experiment in areas off-limits to government agencies.43 Being governed by a small board also offered both flexibility, allowing for rapid change in goals or tactics, and continuity, or the ability to support a project or approach over a long period of time. As a result of their success, they left their mark not only on public health, but also on medical education.44 Historians have explored how a vision of a scientific medicine was promoted and realized by leading figures in Rockefeller philanthropy, such as Abraham Flexner (1866–1959) and Alan Gregg (1890–1957).45 Elizabeth Fee has focused on the early years of the Johns Hopkins School of Public Health and Hygiene, critical to the professionalization of public health in the United States.46 There was much debate over what public health consisted of—a broad field or a specialty built on sanitary engineering and bacteriology, organized around germ theory or the amelioration of environmental conditions based upon scientific research or administrative practice. The Rockefeller Foundation ensured that it would be planned along scientific lines by scientifically trained elite. The biomedical sciences came to dominate at Johns Hopkins and soon throughout the United States—organized around the control of specific diseases, first infectious then chronic, at the expense of the social and political sciences.47 The lack of central government funds and organization meant that public health lacked visibility and definition.48 It also allowed for the development of a diverse field, which combined a range of disciplines and professions and enabled new and innovative programmes to develop—in environmental health, social and behavioural science,

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health economics, population dynamics, and family planning. While further scholarship is required to address the range of agencies and organizations that acted in the absence of a coherent medical specialty, historians have identified a pattern of development that is reflective of American medicine as a whole,49 that is, one of continued pluralism and an ever-increasing interest in the technical possibilities of scientific medicine over community and preventative activities. Just as the Rockefeller Foundation turned from reforming medical schools to supporting individual researchers and projects, leading to considerable eclecticism and incoherence, historians see government agencies as continuing this legacy. The generous government funding given to the National Institutes of Health was distributed across the United States according to a peer-review system, while other opportunistic agencies established their own research programmes, such as the Office of Naval Research.50 This was then coupled to rapidly expanding biotechnology and pharmaceutical industries, again allied to academe.51 The open marketplace so characteristic of American medicine continued, it seems, in biomedical research.52 Big science is America’s solution to sickness—the consequence, perhaps, of its failure to realize a comprehensive national health care system. Understandably, the subject of health insurance has focused attention on the similarities and differences between American and European societies.53 While the passing of the 1911 British Insurance Act helped trigger debate, even optimism, as did the 1946 National Health Service Act, it was not until 1965 that some form of compulsory health insurance was provided in the United States.54 There are, of course, numerous reasons for this failure to reform medical care, many seeing it as stemming from individualistic ideals and a suspicion of government and pointing to the many derogatory references to ‘socialized medicine’. Most also identify the financial and professional interests of physicians as a root cause.55 Having struggled so severely to secure status and income, American physicians feared lowered wages and increased bureaucracy. These concerns were effectively exacerbated and operationalized through the American Medical Association, which manipulated antiGerman feeling and Cold War rhetoric to present compulsory insurance as alien to American society.56 This process has been subject to intense focus by historians, as it is here that many see history as playing a critical role in advising policy, just as it was in the time of Sigerist. However, history is no longer used to assert the seemingly obvious benefits of universal health insurance. Contrary to Sigerist, historians now see its rejection as understandable, perhaps even inevitable, due to a decentralized political system, the weakness of worker unions, the unity of the business sector, and the strength of lobbying by health providers and insurers.57 Yet those who merely associate American medicine with the private sphere are mistaken. As we have seen, American medicine has long combined private and public. The government pays for basic research and training and it patents, regulates, and purchases medical products. Similarly, while the United States may well rely on the private sector to distribute health care, the government has also assumed much of the cost of the provision of clinical services. Charles Rosenberg argues: ‘American distinctiveness lies not in some unique devotion to the market and individualism, but in a widespread

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inattention to a more complex reality.’58 There is a contradiction and tension here that can only be understood historically—the government has continuously filled the gaps in the system, despite near continuous political rhetoric that the state is best kept small. The government first tried to intervene in health care provision as part of the New Deal, but strong opposition forced President Roosevelt to drop health reform from his proposed social security legislation. Seeking to prevent compulsory insurance, the American Medical Association did, however, acquiesce with regard to voluntary insurance. Many physicians were attracted to the idea of a stable and regular income during the Depression, just as hospitals were concerned to realize steady revenue and meet public demand. The result was a series of non-profit group initiatives—Blue Cross for hospital insurance and Blue Shield for physician insurance, and independent consumer cooperatives such as Kaiser Permanente.59 This arrangement satisfied the interests of medical providers, employers, and workers. Shortages in hospital access were met by government through the Hill Burton Act of 1946. With the rising costs of health care provision (inevitable considering the tendency to equate specialization and technology with quality and to define disease according to availability of treatment), government turned to the private sector to invest in health provision, while increasingly providing for those least able to pay.60 The result has been a large section of the population considered too wealthy for government support and too poor to meet spiralling insurance premiums. Rosemary Stevens explores these tensions through the study of the American hospital. This is an institution torn between two competing roles—a social organization that represents charity and public purpose and an icon of capital, competition, and technological achievement.61 For Stevens, the hospital embodies the central dilemma of national health policy: how to share the fruits of medical advance without establishing a large welfare state. The result is an ‘idiosyncratically “American” institution’, defined by technology, expertise, and entrepreneurship, by diversity reflective of the pluralism of American society, and by increased stratification according to class and race.62 That the recent Obama health care legislation did not introduce a universal single payment system, but a complex and ongoing process of reform that includes insurance and pharmaceutical companies, ensures that history will continue to play a critical role in the controversy.

Race and class: from environment, to contagion, to genetic medicine When the sociologist Edward A. Ross (1866–1951) reflected on ‘What is America?’, he expressed a degree of pessimism not uncommon in the Progressive Era.63 America was defined, of course, by the people that inhabited it. It now seemed that the spirited, enterprising, and intelligent Northern European was being overwhelmed by the flood of immigrants from Southern and Eastern Europe. Ross was an outspoken eugenicist, a

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member of a movement that was critical to the association of certain classes and races with hereditary weakness and moral degeneracy. Yet, as Charles Rosenberg argues, the assumed inheritance of physique, character, and temperament was not dependent upon a notion of a discrete and particulate unit of heredity, but reflective of a much older tradition in which ideas of health and illness played a crucial role.64 Disease was associated with certain moral sensibilities and failings. Degenerate characteristics and susceptibilities to illness acquired through poor habits were transmitted to the child, while diseases were spread by the immoral and unsanitary behaviour of certain groups. Through tracing the history of disease in New York, America’s ‘hive of sickness and vice’, particular plagues can be seen to have been associated with particular peoples, irrespective of the understanding of the mode of transmission.65 Even with the arrival of germ theory and the recognition that contagion crossed race and class lines, the perceived relationship between groups and particular diseases was redefined rather than removed. In her study of the polio epidemic of 1916, Naomi Rogers shows how the disease became more visible in the twentieth century following improved sanitation as children no longer acquired immunity through maternal antibodies.66 While it was the middle classes that were now more susceptible and the spread of the disease could be linked to cleanliness and order, scientists and health workers refused to follow this line of investigation. Immigrant families from Southern and Eastern Europe were targeted by the public and by health officials. To retain this association between poverty, immigration, and disease, the fly was enrolled as an explanatory tool—a carrier of disease from working-class to middle-class homes. Alan Kraut and Howard Markel have focused on this association between immigration and illness through the study of epidemics—a useful tool for analysing the various social responses to disease across time and space.67 In his study of the typhus epidemic of 1892 in New York City, Markel examined how scientific debates over germ theory and public health were ignored in favour of targeting immigrants from Eastern Europe as problem populations. Russian Jews were stigmatized as diseased, contributing to the severe immigration restriction legislation of 1924—in many ways a method of quarantine in its broadest sense. It is useful to compare the treatment of various groups in relation to specific diseases and epidemics—trachoma becoming associated with Jewish populations, cholera with the Irish, and, more recently, AIDS with Haitians.68 The Chinese were the first to be excluded from entering the United States on the basis of race. While these restrictions reflected broader cultural concerns over assimilation, they were reinforced by outbreaks of plague in Hawaii in 1899 and San Francisco in 1900. While San Francisco’s Chinatown was known to be filthy and overcrowded, city officials did little to ameliorate the environment. Markel shows how they blamed the immigrants themselves. The result was a coercive, often brutal, self-defeating programme of quarantine involving violence, the forcible removal of families from their homes, the destruction of property, and the closure of businesses. Such historical analyses highlight the tensions and contradictions in focusing on either population or place. In the case presented by Rogers, contagion is presented as a great equalizer, emphasizing the universality of disease, while environmental causes

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focused attention on the dirt and squalor of the working-class home and the incompetence of the working-class family. In the cases presented by Markel, it was the focus on contagious populations that resulted in the poor living conditions of immigrant communities being ignored by city officials. Often modes of explanation discriminate by combining the biological and the environmental. Gregg Mitman’s study of asthma, for example, shows how theories of racial differences in susceptibility to allergens and belief in the unsanitary habits of African American and Latino families resulted in an ‘ecology of injustice’ that ignored appalling housing conditions.69 This focus on specific populations as disease-ridden has only intensified with genetic medicine, particularly with its focus on chronic as opposed to acute illness. Human genetics has been subject to intense historical interest in recent years. For some, the Second World War is a watershed in the history of heredity research; advances in population and medical genetics coupled to the atrocities committed in the name of eugenics transformed the science of heredity and its perceived applications. For most historians, however, there remain significant continuities between the new genetics and earlier attempts to improve the quality of the American population. Tracing the early history of molecular biology, Lily Kay has questioned the common assumption that applied science emerged out of basic research. She suggests the reverse: when the molecular biology programme was first defined in the 1930s, it was done in terms of its perceived technological and social potentials. The Rockefeller millions spent at Caltech reflected a concern with improving man’s mental and physical attributes.70 Historians have, for the most part, sought to qualify what they see as exaggerated optimism over the power and benefit of genetic medicine.71 As Diane Paul argues, diagnostic capabilities far exceed the therapeutic. The oft-celebrated phenylalanine diet for phenylketonuria (PKU)—a celebrated environmental solution to a recently defined genetic disease—is costly and imperfect.72 Methods of gene therapy are as yet limited and have raised concerns over safety. The result is a turn to antenatal diagnostics and selective abortion; for this reason, many see genetic medicine as the thin end of the wedge, a slippery slope or back door towards broader eugenic programmes to improve the genetic quality of populations.73 Such problems are only further compounded by the common associations made between a genetic disease and a particular community. Once again, the diversity of the American population has proven particularly useful for analysing how different communities have very different experiences of genetic medicine. Keith Wailoo and Stephen Pemberton have traced the history of three risk diseases and the people most afflicted by them: cystic fibrosis among the white population; Tay-Sachs in relation to the Jewish American population; and sickle cell anaemia among the black population.74 Different groups meant different promises and programmes. With regard to cystic fibrosis, the focus was on gene therapy, heralded as the new breakthrough in genetic medicine. Tay-Sachs resulted in a well-organized and community-driven programme of self-preservation focused on screening for marriage. Attempts to combat sickle cell anaemia were, in contrast, particularly troubled. While the failure of the government to act against sickle cell was at first seen to reflect their general neglect of African Americans, by the 1970s, following a mandatory screening programme

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and discrimination in health insurance, sport, and employment, there was a backlash against the perceived dangers and stigmatizing potential of genetic medicine. Even today, African Americans are less likely to utilize genetic screening techniques and to avail themselves of selective abortion. The aversion of African Americans to genetic medicine is seen to be understandable when placed in historical context. For Wailoo, the notorious case of the Tuskegee Syphilis Experiment serves as an ‘archetype’ for understanding the relations between race and health care.75 It began in 1932 when approximately 600 African American men in rural Alabama were recruited without their consent into a Public Health Service study of untreated syphilis. When the study ended in 1972, it concluded that the death rate of syphilitic men aged between 25 and 50 was 75 per cent greater than that of the general population. Not only did the authorities fail to treat those infected, but they deliberately prevented them accessing treatment when it became available. Seeking to explain the actions of the investigators, James Jones shows how the study drew from and fed into stereotypes about the sexual behaviour of African Americans.76 Susan Lederer argues that patients were treated as experimental organisms, even cadavers—individuals for dissection identified, and their bodies obtained with the aid of local physicians.77 Understandably, the experiment is a focal point for discussions of racism in science and medicine in America, and continues to trouble the relationship between the medical community and African Americans. However, as Wailoo also argues, the implications of genetic medicine are complex and multifaceted and cannot be understood simply through the prism of biological racism.78 In the 1920s, sickle cell anaemia was seen as a disease of ‘Negro blood’ that could spread through the wider population. It was used, therefore, as a means of arguing against inter-racial marriage. Once it was understood to be carried by a recessive allele in the 1940s, its social significance was radically altered. Out-breeding would now reduce its incidence. Wailoo argues that sickle cell anaemia has two very different identities, a consequence of new methods and technologies. By the 1950s, sickle cell had become an exemplar of genetic polymorphism—its role in protecting a carrier against malaria making it essential to the survival of a population. The lack of attention given to issues such as genetic diversity and polymorphism is the result of the preoccupation of historians with the relations between genetic medicine and eugenics. Only recently are we seeing work that addresses the ways in which genetic medicine was transformed, in the words of Susan Lindee, from ‘medical backwater’ to ‘medical research frontier’, and how various advocacy groups helped to drive this growing industry of blood-testing techniques, population-mapping studies, and screening programmes.79

Conclusion Historians of medicine have long focused on disease, the more dramatic and visible the better, as a means of understanding tension, contradiction, continuity, and change in American society. In a classic example, Charles Rosenberg used cholera epidemics as a

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‘natural experiment’ and ‘sampling technique’ as well as a subject—a ‘randomly recurring stimulus against which the varying reactions of Americans could be judged’.80 Similarly, in Katherine Ott’s study of tuberculosis, the identity of the disease was not the same in 1870, 1900, or 1930.81 Diseases are framed by the society in which they exist, and, as Keith Wailoo argues, it is by tracing their trajectory as social commodities that we reveal the general trajectory of American health care and biomedical research.82 Others have focused on a disease across space as opposed to time, a cross-sectional ‘snapshot’ if you will, of the differential experience of health and sickness among the various groups that make up American society. In such studies, historians have become increasingly aware of the methods, practices, and technologies that drive our social understanding of illness across time and space. New technologies not only make visible and give definition to specific diseases, but they can also redefine notions of health and illness more generally. Health and population surveys, for example, are extremely important to medical science, yet they have been largely neglected as a historical resource. Just as Margo Anderson used the history of the US census as a window through which to view American political, economic, and scientific life, in tracing surveys, many still ongoing, we are offered insights into the shifting landscape of health and health research in the United States.83 The Framingham Heart Study, for example, began in 1947 and pioneered the epidemiological study of chronic disease and contributed to our understanding of a ‘risk’ population.84 Framingham was considered an ideal sample of the American population and had been studied before as a means of understanding an infectious disease—tuberculosis. It became a ‘social laboratory’ focused on a wide range of variables, normal as well as pathological. Like numerous other surveys, it not only mirrors the changes in American society and medicine, but actively contributes to them, allowing us to examine the effects of new measures and technologies, the continuous negotiation between interested parties over the questions asked and the application of data, and the experience of existing under the medical gaze. A focus on such methods not only allows us to examine populations across time and space, but also to privilege the problem of place. This has become of increasing interest to historians of science and medicine in recent years. Tom Gieryn’s suggestion that there exist ‘truth-spots’, for example, places associated with a particular form of knowledge production to which they lend credibility,85 could also be usefully applied to the history of medicine—places associated with the study of health and disease. Attention has also been stimulated by work that recognizes the central role that health and medicine play in environmental history.86 The idea of places of health and sickness, it is argued, allows us to traverse boundaries between humans and nature and between urban and rural environments. The tremendous upheavals of urban renewal, for example, in which physical and mental health concerns proved critical as a source of justification and criticism, have been largely ignored by historians of American medicine.87 The great multiplicity and change in peoples and places in the United States will continue to provide a rich field of research, while the complexity of relations between citizens and federal, state, and local government

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will always provide tensions and contradictions of interest to the historian of medicine.

Notes 1. Alexis de Tocqueville, Democracy in America, ed. J. P. Mayer with a new translation by George Lawrence (Garden City, NY: Doubleday, 1969). 2. Tocqueville, Democracy in America, (1969), 454–5. 3. H. E. Sigerist, American Medicine (New York: Norton, 1934), xvi. 4. Elizabeth Fee and T. M. Brown (eds), Making Medical History: The Life and Times of Henry E. Sigerist (Baltimore: Johns Hopkins University Press, 1997), 25. 5. H. E. Sigerist, Medicine and Human Welfare (College Park, MD: McGrath, [1945] 1971). 6. Charles Rosenberg, Our Present Complaint: American Medicine Then and Now (Baltimore, Johns Hopkins University Press, 2007). 7. Colin G. Calloway, New Worlds for All: Indians, Europeans and the Remaking of Early America (Baltimore: Johns Hopkins University Press, 1997), 25. 8. Russell Thornton, American Indian Holocaust and Survival: A Population History since 1492 (Norman: University of Oklahoma Press, 1987). 9. Henry F. Dobyns, ‘Estimating Aboriginal American Population’, Current Anthropology 7 (1966), 395–416; idem, Native American Historical Demography (Bloomington: Indiana University Press, 1976); idem, Their Number Become Thinned: Native American Population Dynamics in Eastern North America (Knoxville: University of Tennessee Press, 1983). Another classic is A. W. Crosby, The Columbian Exchange: Biological and Cultural Consequences of 1492 (Westport, CT: Greenwood Press, 1972). 10. Francis Jennings, The Invasion of America: Indians, Colonialism, and the Cant of Conquest (Chapel Hill: University of North Carolina Press, 1975), 15. 11. Calloway, New Worlds for All, 39–40; P. Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge: Cambridge University Press, 1999). 12. Gerald N. Grob, The Deadly Truth: A History of Disease in America (Cambridge, MA: Harvard University Press, 2002), 52. 13. James H. Cassedy, Demography in Early America: Beginnings of the Statistical Mind, 1600– 1800 (Cambridge, MA: Harvard University Press, 1969); Dennis Hodgson, ‘Benjamin Franklin on Population: From Policy to Theory’, Population and Development Review 17 (1991), 639–61. 14. Richard, H. Steckel, ‘Heights and Human Welfare: Recent Developments and New Directions’, Explorations in Economic History 46 (2009), 1–23; Bernard Harris, ‘Health, Height, and History: An Overview of Recent Developments in Anthropometric History’, Social History of Medicine 7 (1994), 297–320. 15. Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962). 16. K. David Patterson, ‘Disease Environments of the Antebellum South’, in Ronald L. Numbers and Todd L. Savitt (eds), Science and Medicine in the Old South (Baton Rouge: Louisiana State University Press, 1989), 152–72; John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990). 17. Ronald Numbers (ed.), Medicine in the New World: New Spain, New France, and New England (Knoxville: University of Tennessee Press, 1987), 2, 157.

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18. Lisa Rosner, ‘Thistle on the Delaware: Edinburgh Medical Education and Philadelphia Practice, 1800–1825’, Social History of Medicine 5 (1992), 19–42. 19. Charles Rosenberg, ‘The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth-Century America’, Perspectives in Biology and Medicine 20 (1977), 485–506. 20. Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982). 21. Ronald Numbers, ‘The Fall and Rise of the American Medical Profession’, in Nathan Hatch (ed.), The Professions in American History (Notre Dame: University of Notre Dame Press, 1988); Martin Kaufman, ‘American Medical Education’, in Ronald Numbers (ed.), The Education of American Physicians: Historical Essays (Berkeley: University of California Press, 1980). 22. John Harley Warner, Against the Spirit of the System: The French Impulse in NineteenthCentury American Medicine (Baltimore: Johns Hopkins University Press, 1998). 23. John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820–1885 (Cambridge, MA: Harvard University Press, 1986), 3. 24. James O. Breeden, ‘Disease as a Factor in Southern Distinctiveness’, in Todd Savitt and James Harvey Young (eds), Disease and Distinctiveness in the American South (Knoxville: University of Tennessee Press, 1988), 1–28. 25. Patterson, ‘Disease Environments’, 158. 26. Margaret Humphreys, Yellow Fever and the South (New Brunswick, NJ: Rutgers University Press, 1992), 1. See also: John H. Ellis, Yellow Fever and Public Health in the New South (Lexington: University Press of Kentucky, 1992); and Jo Ann Carrigan, ‘Yellow Fever: Scourge of the South’, in Savitt and Young (eds), Disease and Distinctiveness in the American South. 27. Richard H. Steckel, ‘A Peculiar Population: The Nutrition, Health, and Mortality of American Slaves from Childhood to Maturity’, Journal of Economic History 46 (1986), 721–41. 28. Todd L. Savitt, ‘Black Health on the Plantation: Masters, Slaves, and Physicians’, in Numbers and Savitt (eds), Science and Medicine in the Old South; Savitt and Young (eds), Disease and Distinctiveness in the American South; Todd Savitt, Medicine and Slavery: The Diseases and Health Care of Blacks in Antebellum Virginia (Urbana: University of Illinois Press, 1978). 29. Sharla M. Fett, Working Cures: Healing, Health, and Power on Southern Slave Plantations (Chapel Hill: University of North Carolina Press, 2002). 30. Todd L. Savitt, Race and Medicine in Nineteenth- and Early-Twentieth-Century America (Kent, OH: Kent State University Press, 2007). 31. Numbers, ‘The Fall and Rise’. 32. John Harley Warner, ‘Ideals of Science and Their Discontents in Late-NineteenthCentury American Medicine’, Isis 82 (1991), 454–78. For an analysis of the strength of emphasis on scientific training and practical experience in the United States, see Thomas Neville Bonner, ‘The German Model of Training Physicians in the United States, 1870– 1914: How Closely Was It Followed?’, Bulletin of the History of Medicine 64 (1990), 18–34. 33. William H. Schneider, ‘The Men Who Followed Flexner: Richard Pearce, Alan Gregg, and the Rockefeller Foundation Medical Divisions, 1919–1951’, in William H. Schneider (ed.), Rockefeller Philanthropy and Modern Biomedicine: International Initiatives from World War I to the Cold War (Bloomington: Indiana University Press, 2002), 7–60, at 10–11.

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34. Vannevar Bush, Science, the Endless Frontier: A Report to the President (Washington, DC: United States Government Printing Office 1945), 5, Robert Cook-Deegan and Michael McGeary, ‘The Jewel in the Federal Crown?: History, Politics, and the National Institutes of Health’, in Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns (eds), History and Health Policy in the United States: Putting the Past Back In (New Brunswick, NJ: Rutgers University Press, 2006), 176–201, at 179. 35. Fitzhugh Mullan, Plagues and Politics: The Story of the United States Public Health Service (New York: Basic Books, 1989). 36. E. Richard Brown, Rockefeller Medicine Men: Medicine and Capitalism in America (Berkeley: University of California Press, 1979); Jack D. Pressman, ‘Human Understanding: Psychosomatic Medicine and the Mission of the Rockefeller Foundation’, in Christopher Lawrence and George Weisz (eds), Greater Than the Parts: Holism in Biomedicine, 1930– 1950 (New York: Oxford University Press, 1998). For studies of other foundations relevant to health, see A. McGehee Harvey and Susan L. Abrams, ‘For the Welfare of Mankind’: The Commonwealth Fund and American Medicine (Baltimore: Johns Hopkins University Press, 1986); Clyde V. Kiser, The Milbank Memorial Fund: Its Leaders and Its Work, 1905–1974 (New York: Milbank Memorial Fund, 1975). 37. John Ettling, The Germ of Laziness: Rockefeller Philanthropy and Public Health in the New South (Cambridge, MA: Harvard University Press, 1981); John Farley, To Cast Out Disease: A History of the International Health Division of the Rockefeller Foundation (1913–1951) (New York: Oxford University Press, 2004). 38. Elizabeth Toon, ‘Selling the Public on Public Health: The Commonwealth and Milbank Health Demonstrations and the Meaning of Community Health Action’, in Ellen Condliffe Lagemann (ed.), Philanthropic Foundations: New Scholarship, New Possibilities (Bloomington: University of Indiana Press, 1999), 119–30. 39. Ettling, The Germ of Laziness, viii. 40. Soma Hewa, Colonialism, Tropical Disease and Imperial Medicine: Rockefeller Philanthropy in Sri Lanka (Lanham: University Press of America, 1995). 41. Anne-Emanuelle Birn, Marriage of Convenience: Rockefeller Health and Revolutionary Mexico (Rochester, NY: University of Rochester Press, 2006); Schneider (ed.), Rockefeller Philanthropy and Modern Biomedicine; Ann Zulawski, Unequal Cures: Public Health and Political Change in Bolivia, 1900–1950 (Durham, NC/London: Duke University Press, 2007). 42. Benjamin B. Page and David A. Valone (eds), Philanthropic Foundations and the Globalization of Scientific Medicine and Public Health (Lanham: University Press of America, 2007). 43. Adele Clarke, Disciplining Reproduction: Modernity, American Life Sciences, and ‘The Problems of Sex’ (Berkeley: University of California Press, 1998); Mathew Connelly, Fatal Misconceptions (Cambridge, MA: Belknap Press, 2008); Elizabeth Fee, ‘Sin vs Science: Venereal Disease in Baltimore in the Twentieth Century’, Journal of the History of Medicine and Allied Sciences 43 (1988), 141–64. 44. Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (Baltimore: Johns Hopkins University Press, 1985). 45. Barbara Barzansky and Norman Gevitz (eds), Beyond Flexner: Medical Education in the Twentieth Century (Westport, CT: Greenwood Press, 1992); Howard S. Berliner, A System of Scientific Medicine: Philanthropic Foundations in the Flexner Era (London/New York: Tavistock, 1985); Schneider, ‘The Men Who Followed Flexner’.

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46. Elizabeth Fee, Disease and Discovery: A History of the Johns Hopkins School of Hygiene and Public Health, 1916–1939 (Baltimore: Johns Hopkins University Press, 1987); Elizabeth Fee and Roy M. Acheson (eds), A History of Education in Public Health: Health That Mocks the Doctor’s Rules (Oxford: Oxford University Press, 1991). 47. See also James Colgrove, Gerald Markowitz, and David Rosner, The Contested Boundaries of American Public Health (New Brunswick, NJ: Rutgers University Press, 2008). 48. Elizabeth Fee, ‘The Origins and Development of Public Health in the United States’, in Roger Detels, et al. (eds), Oxford Textbook of Public Health, vol. 1 (Oxford: Oxford University Press, 1997), 35–54, at 49. 49. An example of a hugely influential organization in need of historical analysis would be the Metropolitan Life Insurance Company. There is also still considerable work to do on various foundations such as the Milbank Memorial, Josiah Macy Jr, and Rosenwald Funds. 50. Victoria A. Harden, Inventing the NIH: Federal Biomedical Research Policy, 1887–1937 (Baltimore: Johns Hopkins University Press, 1986); Harvey M. Sapolsky, Science and the Navy: The History of the Office of Naval Research (Princeton: Princeton University Press, 1990). There is still considerable work to be done on both the Navy and Army in relation to medical and psychiatric research. 51. Eli Ginzberg and Anna B. Dutka, The Financing of Biomedical Research (Baltimore: Johns Hopkins University Press, 1989); John P. Swann. Academic Scientists and the Pharmaceutical Industry: Cooperative Research in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1988). 52. Cook-Deegan and McGeary, ‘The Jewel in the Federal Crown?’ 53. There is a tendency to compare the United States with Britain in particular, the nations having important social, cultural, political, and scientific ties. The potentially useful comparison with Canada is rarely undertaken. See, for example, Theodore R. Marmor, ‘Canada’s Path, America’s Choices: Lessons from the Canadian Experience with National Health Insurance’, in R. Numbers (ed.), Compulsory Health Insurance: The Continuing American Debate (Westport, CT: Greenwood, 1982). For further discussion of these issues, see Chapter 24 by Martin Gorsky in this volume. 54. Gary Land, ‘American Images of British Compulsory Health Insurance’, in Numbers (ed.), Compulsory Health Insurance. 55. Jonathan Engel, Doctors and Reformers: Discussion and Debate over Health Policy, 1925– 1950 (Columbia: University of South Carolina Press, 2002); Ronald L. Numbers, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920 (Baltimore: Johns Hopkins University Press, 1978); Numbers (ed.), Compulsory Health Insurance. 56. Ronald Numbers, ‘The Third Party: Health Insurance in America’, in Morris J. Vogel and Charles E. Rosenberg (eds), The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia: University of Pennsylvania Press, 1979), 177–200. 57. Jonathan Engel, Poor People’s Medicine: Medicaid and American Charity Care since 1965 (Durham, NC: Duke University Press, 2006), xv–xvi. 58. Rosenberg, Our Present Complaint, 186–7. 59. Robert Cunningham III and Robert M. Cunningham Jr., The Blues: A History of the Blue Cross and Blue Shield System (Dekalb: Northern Illinois University Press, 1997); Michael R. Grey, New Deal Medicine: The Rural Health Programs of the Farm Security Administration (Baltimore: Johns Hopkins University Press, 1999); Rickey Hendricks, A Model for National Health Care: The History of Kaiser Permanente (New Brunswick, NJ: Rutgers University Press, 1993).

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60. Stevens, Rosenberg, and Burns (eds), History and Health Policy in the United States; Lawrence D. Brown, Politics and Health Care Organization: HMOs as Federal Policy (Washington, DC: Brookings Institution, 1983). 61. Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), 4. 62. Ibid. 8. 63. Edward A. Ross, What Is America? (New York: Century, 1919). 64. Charles E. Rosenberg, No Other Gods: On Science and American Social Thought (Baltimore: Johns Hopkins University Press, 1976). 65. David Rosner (ed.), Hives of Sickness: Public Health and Epidemics in New York City (New Brunswick, NJ: Rutgers University Press, 1995). 66. Naomi Rogers, Dirt and Disease: Polio before FDR (New Brunswick, NJ: Rutgers University Press, 1992). 67. Alan M. Kraut, Silent Travelers: Germs, Genes, and the ‘Immigrant Menace’ (Baltimore: Johns Hopkins University Press, 1994); Howard Markel, Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892 (Baltimore: Johns Hopkins University Press, 1997). 68. Howard Markel, When Germs Travel: Six Major Epidemics That Have Invaded America since 1900 and the Fears They Have Unleashed (New York: Pantheon Books, 2004). 69. Gregg Mitman, ‘Cockroaches, Housing, and Race: A History of Asthma and Urban Ecology in America’, in Mark Jackson (ed.), Health and the Modern Home (New York/ London: Routledge, 2007), 244–65. 70. Lily E. Kay, The Molecular Vision of Life: Caltech, the Rockefeller Foundation, and the Rise of the New Biology (Oxford: Oxford University Press, 1993). 71. Joseph S. Alper, Catherine Ard, Adrienne Asch, Jon Beckwith, Peter Conrad, and Lisa N. Geller (eds), The Double-Edged Helix: Social Implications of Genetics in a Diverse Society (Baltimore: Johns Hopkins University Press, 2002); Dorothy Nelkin and Laurence Tancredi, Dangerous Diagnostics: The Social Power of Biological Information (Chicago: University of Chicago Press, 1989). 72. Diane Paul, ‘A Double-Edged Sword’, Nature 405 (2000), 515. 73. Troy Duster, Backdoor to Eugenics (London: Routledge, 1990). 74. Keith Wailoo and Stephen Pemberton, The Troubled Dream of Genetic Medicine: Ethnicity and Innovation in Tay-Sachs, Cystic Fibrosis, and Sickle Cell Disease (Baltimore: Johns Hopkins University Press, 2006). 75. Keith Wailoo, Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health (Chapel Hill: University of North Carolina Press, 2001), 13. 76. James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment (New York: Free Press, 1993). 77. Susan Lederer, ‘Tucker’s Heart: Racial Politics and Heart Transplantation in America’, in Keith Wailoo, Julie Livingston, and Peter Guarnaccia (eds), A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of Medical Citizenship (Chapel Hill: University of North Carolina Press, 2006). 78. Keith Wailoo, Drawing Blood: Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1997), 137. 79. Susan Lindee, Moments of Truth in Genetic Medicine (Baltimore: Johns Hopkins University Press, 2005), 1.

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80. Rosenberg, The Cholera Years, 4; Charles Rosenberg, ‘Siting Epidemic Disease: 3 Centuries of American History’, Journal of Infectious Diseases, 197 (2008), S4–S6. 81. Katherine Ott, Fevered Lives: Tuberculosis in American Culture since 1870 (Cambridge, MA: Harvard University Press, 1996). 82. Wailoo, Dying in the City, 9. 83. Margo Anderson, The American Census: A Social History (New Haven, CT: Yale University Press, 1988). 84. Gerald M. Oppenheimer, ‘Becoming the Framingham Study, 1947–1950’, American Journal of Public Health 95 (2005), 602–10. 85. Thomas F. Gieryn, ‘City as Truth-Spot: Laboratories and Field-Sites in Urban Studies’, Social Studies of Science 36 (2006), 5–38. 86. Gregg Mitman, ‘In Search of Health: Landscape and Disease in American Environmental History’, Environmental History 10 (2005), 184–210; Dawn Biehler, ‘Permeable Homes: A Historical Political Ecology of Insects and Pesticides in US Public Housing’, Geoforum 40 (2009), 1014–23; Michelle Murphy, Gregg Mitman, and Christopher Sellers (eds), Landscapes of Exposure: Knowledge and Illness in Modern Environments, Osiris 19 (2004); Michelle Murphy, Sick Building Syndrome and the Problem of Uncertainty: Environmental Politics, Technoscience, and Women Workers (Durham, NC: Duke University Press, 2006). 87. There is also work needed that addresses medical sociology, social psychiatry, and the relationship between medicine and the behavioural sciences more generally—see, for example, Samuel W. Bloom, The Word as Scalpel: A History of Medical Sociology (Oxford: Oxford University Press, 2002).

Select Bibliography Fee, Elizabeth, and Roy M. Acheson (eds), A History of Education in Public Health: Health That Mocks the Doctor’s Rules (Oxford: Oxford University Press, 1991). —— , and T. M. Brown (eds), Making Medical History: The Life and Times of Henry E. Sigerist (Baltimore: Johns Hopkins University Press, 1997). Grob, Gerald, The Deadly Truth: A History of Disease in America (Cambridge, MA: Harvard University Press, 2002). Leavitt, Judith Walzer, and Ronald L. Numbers (eds), Sickness and Health in America: Readings in the History of Medicine and Public Health (Madison: University of Wisconsin, 1997). Numbers, Ronald (ed.), Compulsory Health Insurance: The Continuing American Debate (Westport, CT: Greenwood, 1982). —— , and Todd L. Savitt (eds), Science and Medicine in the Old South (Baton Rouge: Louisiana State University Press, 1989). Rosenberg, Charles E., Our Present Complaint: American Medicine, Then and Now (Baltimore: Johns Hopkins University Press, 2007). Starr, Paul, The Social Transformation of American Medicine (New York: Basic Books, 1982). Stevens, Rosemary A., Charles E. Rosenberg, and Lawton R. Burns (eds), History and Health Policy in the United States: Putting the Past Back In (New Brunswick: Rutgers University Press, 2006). Warner, John Harley, and Janet A. Tighe (eds), Major Problems in the History of American Medicine and Public Health (Boston: Houghton Mifflin, 2001).

chapter 14

pu blic h e a lth a n d m edici n e i n l ati n a m er ica a nne-emanuelle birn

The countries of Latin America are enormously diverse demographically, geographically, politically, economically, and culturally, yet they share certain features, providing coherence to thinking about the history of health and medicine in regional terms. Subject to Iberian colonialism roughly from the late fifteenth to the nineteenth centuries, the countries that now constitute Latin America (Mexico, Spanish Central America, Cuba, Puerto Rico, and the Dominican Republic in the Caribbean, and ten of the thirteen countries in South America) share intertwining historical, linguistic, and cultural legacies.1 Iberian imperialism included a particularly strong role for the Catholic Church, which heavily influenced medical and public health practices but never fully displaced traditional practitioners and healing ideologies, especially, but not only, in settings where significant indigenous populations survived European conquest. Linguistic–cultural relations in Spanish Latin America (and with and within Portuguese Latin America) enabled limited interchange in the colonial era, for example through circulating materia medica, the work of Jesuits in medical geography, and colonial efforts at the control of epidemics. With the exception of Cuba and Puerto Rico, contemporary Latin American republics achieved political independence in the nineteenth century; across northern and western South America the liberation movement was led and inspired by Simon Bolívar (1783–1830). In the case of Brazil, the exiled Portuguese monarchy created a displaced Brazilian Empire in 1822, which lasted until 1889. Throughout the region, professional ties and conflict—typically regarding the spread of epidemic disease—were enhanced after the old order was toppled and rapidly accelerated in the nineteenth century with the rise of sea and rail transport and an increase in commerce. After independence, European economic and cultural interests in the region persisted, broadening far beyond the former colonial powers to include, for example, English, French, and Dutch financial investments, and waves of immigrants from

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Southern and Eastern Europe, Asia, the Middle East, and beyond. Meanwhile, US political and economic power in the region mounted. These developments were reflected in medical ideas, organization, and practice. For example, post-revolutionary French medicine served as the predominant (but not the sole) model for the nineteenth- and early twentieth-century institutionalization and professionalization of health and medical fields; US medical influence accelerated after the Second World War, occasionally challenged by Soviet interests. While Latin American health and medicine have long been viewed as derivative, more recent scholarship shows considerable regional innovation and the worldwide reverberation of a range of ‘homegrown’ medical ideas and practices, public health policies, and health care organizational models. Today, the region is characterized by enormous inequities, with seemingly insurmountable divides in health conditions and in medical and health services (related to research and professionalization) between elites, a precarious middling group, and large marginalized populations. Even so, certain locales (including Costa Rica and Cuba) have admirably addressed social inequalities in health. This chapter addresses these developments, diversities, and congruities through five historical eras and thematic perspectives and concludes with an analysis of historiographical approaches in the contemporary context, exploring the major challenges facing historians writing about Latin American health and medicine today, particularly the links between history and contemporary national and global health policy issues. From a historiographical perspective, work on Latin American health and medicine followed a fairly traditional ‘doctors and discoveries’ trajectory through the 1960s, with two overlapping features distinguishing it from the Anglo-European literature: the very writing of medical history in the so-called periphery led to a far earlier recognition of the role of colonial authorities and institutions in shaping national and regional trends than among ‘metropolitan’ scholars; and some pioneering scholars addressed the role of indigenous medical practice (if typically disparagingly) and syncretism in the shaping of Latin American medicine.2 That said, these hagiographic approaches tended to overemphasize the one-way influence and importance of European medical developments. In the 1970s, a new generation of historians of health and medicine in various Latin American countries, marked by Marxist ideas and political movements, brought materialist and political economy explanations to the fore, paying special attention to imperialism and medicine; in subsequent decades the ideas of Michel Foucault and Pierre Bourdieu surfaced to shape more theoretical work that was sometimes short on empirical research, due to limited funding and archival access. By the 1990s, a new generation of historians of Latin American health and medicine emerged from throughout the Americas and beyond, leading to a flourishing of the field. Trained with sensibilities to the social history of medicine and to class, race/ethnicity, and gender/sexuality approaches, and benefiting from the reorganization of archives and opening up of the academic world following many years of repression and political and economic instability through much of the region, these historians have been producing some of the world’s most exciting scholarship in the history of medicine and health, with less-than-deserved audiences due to language barriers.

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Pre-Columbian health conditions and the impact of the European conquest There is little surviving evidence concerning health and healing in pre-Columbian societies, though enduring practices of Kallawaya, Nahua, Aymara, and other indigenous healers, together with anthro-archaeological and iconographic sources, as well as the various codices and natural histories compiled by European colonists, provide useful sketches. The Maya, for example, considered children to be a sign of good fortune and paid special attention to infant health. Aztec children even had their own medical god, Ixtlilton, a deity unknown elsewhere in the world. Various pre-Columbian populations are known for their adherence to hygienic precepts—such as bathing rituals following childbirth, widespread breastfeeding for the first several years of life, testing the milk of wet nurses, and monitoring the nursing mother’s diet—and for treating ailments with a combination of magic and empiricism. Together these measures may account for a life expectancy estimated at approximately ten years longer than that of medieval and early-modern Europeans. The Spanish and Portuguese (and later French, British, and Dutch) invasions and imperialist systems had a devastating demographic impact on indigenous populations across the Americas. Most infamously, smallpox is believed to have been spread throughout Meso-America through distribution of infected blankets by the forces of Spanish conquistador Hernán Cortés (1485–1547), though mortality from forced labour was likely to have been far higher. All told, between one-third and one-half of local inhabitants of the region were killed in the late fifteenth and sixteenth centuries by warfare, forced labour and relocation, and epidemic mortality from measles, smallpox, and other infectious diseases, all caused or facilitated by the military, economic, and social aspects of the conquest.3 Unquestionably, pre-Columbian societies in Meso-America experienced colossal mortality from violence, occasional famine, and infectious diseases,4 but the conquest stands out because of the magnitude of death as well as the enormous mortality differential between invaders and invaded. Iberian invaders used this differential to military and cultural advantage, trumpeting the presumed constitutional superiority of the invaders, understood today to be the result of immunity due to previous exposure to micro-organisms.

Colonial era medical authority, healers, and epidemic control By the sixteenth century, Spanish authorities were carrying European medical practices to the viceroyalties in New Spain and Peru (in the eighteenth century further divided into viceroyalties of New Granada and Río de la Plata). Colonial Spanish and Portuguese

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administrations supported the founding of medical faculties in leading colonial cities, such as Lima and Salvador da Bahia, and, greatly abetted by the Catholic Church, built hundreds of hospitals across the continent separately serving colonists and native populations. Medical practitioners joined colonial ventures, initially hired by conquistadores to protect military forces. Since few medical elites were attracted by the low salaries and dangers of practice in the colonies, a range of popular healers and charlatans also migrated. As region after region came under European control, elite physicians began to be integrated into colonial authority structures. Immigrant and criollo medical authorities established strict rules about who could and could not practise medicine based on race, religious faith, sex, and social background. Despite certain well-publicized prosecutions for violators, these rules were often flouted. Up and down the continent, a new hierarchy of medical practitioners was established, with titled physicians serving urban elites, Catholic hospitals providing charity care, and traditional healers and midwives—who began to meld the beliefs of a wide variety of indigenous cultures with Galenic and herbalist practices from Europe—attending the majority of the population.5 Religious missionaries—first Catholic, later joined by Protestant denominations—played a large role in building and running leprosaria and hospitals, intertwining medical and religious proselytization. Officially sanctioned physicians sought the power of the Protomedicato (medical board) to squeeze out illegal or impure healers but met with little success.6 A fragmented and overlapping set of health authorities also emerged, with the viceroy and religious agencies overshadowing the regulatory role of the Protomedicato during epidemic times.7 In all settings, imperial medical activities met with long-standing healing traditions, in which women played vital roles. In Meso-America, curanderas and brujas—female spiritual healers—retained their authoritative community roles under Spanish colonialism and, like their male healer counterparts, integrated various Galenic concepts brought by the Europeans, such as the idea of hot and cold causes and therapies for disease, with indigenous practices of spiritism, magic and divination, herbalism, and evil air healing. Where African slaves were imported as labourers, most notably in Brazil and the Caribbean, a variety of African spirito-healing practices were a major influence on the evolving medical syncretism. Medical ideologies, institutions, and practices were central to the activities of conquest, subjugation, and economic exploitation that characterized the Euro-American imperial enterprise. Initially women healers were not considered important to the mission of ‘civilizing’ local populations, increasing labour productivity, and controlling epidemics, but over time they were recognized as important targets, interlocutors, and purveyors of imperial health efforts. In colonial Mexico and Central America, traditional midwives—parteras—maintained their primary purview over pregnancy, childbirth, and infant health even as Bourbon and, from the nineteenth century onwards, republican administrations attempted to regulate and displace them. Medical authorities blamed midwives for infant and maternal deaths and continuously pressed for midwifery training (and for a more circumscribed role for the midwife), licensing, or outright elimination. However, Mexican midwives were not covered by licensing

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regulations until 1945, and empirical midwives continue to practise in many indigenous communities and beyond.8 One key reason for the survival of midwives in Mexico and elsewhere, despite persistent attacks on their legitimacy, was their comprehensive approach. Prenatal care involved observing the colour of nipples, the shape of the womb and the position of the foetus, and relieving physical ailments through massage and herbal remedies. Following childbirth, the midwife aided the new mother with household chores, offering both emotional and physical support. Within a few weeks after delivery (and sometimes during pregnancy and the early stages of childbirth), the new mother took one or more temazcalli, therapeutic steam baths, which served to cleanse her physically, ritually, and emotionally. Midwives and their patients believed that the baths increased the flow of milk, prevented illness, and helped adjust the balance of hot and cold influences. Given the paucity of therapeutic measures in the European medical armamentarium, the Iberian invaders were eager to learn of indigenous healing knowledge and the local pharmacopoeia, and began to sponsor catalogues of this knowledge. The earliest and most important of these was the Codex Badianus of 1552, an illustrated compendium of hundreds of medicinal herbs. Written in Nahuatl by Martin de la Cruz and translated into Latin by Juan Badiano (both Aztec men who had trained in a Mexico City Franciscan academy), it was produced for the Spanish Emperor. In Brazil, the Jesuits played a fundamental role in colonial medical care from 1554 until their expulsion two centuries later, similarly learning from indigenous botanical knowledge and mixing local and European healing practices. Notwithstanding colonial medical investments, there is ample evidence that sanitary and living conditions—and the associated gastrointestinal and respiratory mortality— worsened markedly under Spanish and Portuguese imperialism. The Mexica (Aztecs), for example, kept the streets, markets, and plazas of their capital Tenochtitlán conspicuously clean through regular refuse collection and extensive sanitary and hygienic measures; waste water was carefully separated from the clean sources of Lake Texcoco, which surrounded the city.9 But after Tenochtitlán was destroyed and rebuilt as Mexico City under Spanish rule, Lake Texcoco was transformed into a giant cesspool: landfill projects, heavy canal commerce, and inadequate sewage disposal led to frequent flooding and contamination, with highly damaging health consequences.10 Throughout the colonial period and after, disease and death were rife among Mestizos, and, especially, indigenous and African-descended populations due to a variety of factors: conflict; slavery or indentured servitude; dangerous work in mines, building sites, and plantations; dispossession from land, cultural heritage, and livelihoods; crowded living conditions in towns; food shortages; trade and travel; and ecological alterations (canalization, railways, and exploitation of forests) facilitating mosquito breeding sites and malaria. To be sure, colonists also suffered widely from infectious and childhood diseases, but occupational mortality and early death among Mestizo labourers, African slaves, and indigenous groups, coupled with staggeringly high infant mortality rates, meant that these groups on average lived far shorter and sicklier lives than Iberian elites. Some cities, such as Veracruz and Caracas, began to implement environmental and

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sanitary measures that were partially effective at controlling yellow fever and other disease outbreaks.11 Many others struggled with highly fatal outbreaks of a range of infectious diseases well into the twentieth century.12 The most unifying episode of late Spanish medical colonialism was linked to the very ailment that had been so destructive upon conquest: smallpox. When English surgeon Edward Jenner (1749–1823)—observing milkmaids around 1796—found that vaccination with cowpox (generally not deadly to humans) could prevent smallpox in humans, he helped transform smallpox prevention into a far safer endeavour. In 1803, Charles IV, the Bourbon King of Spain, having lost a child to smallpox, sponsored an extraordinary expedition throughout the Spanish Empire. The small Balmis-Salvany group arrived in Puerto Rico in 1804, and then travelled on to Venezuela, Panama, Colombia, Ecuador, Peru, Chile, and Bolivia, administering smallpox vaccine throughout these territories on foot, horseback, and along waterways. Because there was no means of preserving the vaccine, it was administered live—arm to arm— preserved in the bodies of twenty-one Spanish orphans, with instructions for preparation passed along.13 This first mass health campaign was a distant prelude to the World Health Organization’s smallpox eradication campaign, conducted almost three centuries later.14

Nineteenth-century institutional growth and struggles over medical pluralism The wave of insurgencies and full-scale wars that undulated through Latin America between 1800 and 1825 brought independence to all of the region’s Iberian colonies except Puerto Rico and Cuba (with Brazil becoming a republic in 1889). However, political turmoil, continued warfare within and between countries, and, in some settings, foreign occupation restricted the contours of nation-building. Following decades of instability, the region began to see greater trade, foreign investment, and economic development in the mid-nineteenth century, yet the social order and agrarian basis of most of the population remained largely unchanged from the colonial period. Moreover, the weak states of newly independent Latin America typically decentralized political power to local jurisdictions. In health terms, this situation meant that there was little effort to document or address problems, particularly in rural areas. Even amidst the chaos of nineteenth-century independence struggles and unstable new republics, there was a burgeoning of national medical institutions throughout the region. In most Latin American countries, the sanitary authorities that had periodically mobilized to combat epidemic outbreaks during centuries of Spanish and Portuguese colonialism were transformed into permanent hygiene boards and departments. Infused with the new ideas and practices of the day, national health agencies sought to

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implement modern measures and increase state purview over social welfare. These efforts took place mostly in leading cities, with sanitation catering to elites, child health aimed at the poor, and food and housing regulations monitored fitfully. As the number and range of public health tools—from Wasserman tests to mosquito larvae control— increased after 1900, medico-civic professionals throughout Latin America advocated greater attention to endemic problems. Still, health authorities in many settings were hampered by limited state capacity and low responsiveness to popular needs: the region’s large rural populations were typically allotted few systematic health improvements beyond vaccination campaigns and epidemic disease control. By the second half of the nineteenth century, attention to health and social welfare increased in capitals and larger cities, with initially limited participation of most central governments. Since political administrations in this period were often short-lived, charitable and religious agencies— with considerable involvement of middle- and upper-class women—provided the institutional base and continuity for measures to protect health, particularly of women and children. The institutional evolution of Mexican medicine is illustrative of developments throughout Latin America in this era. Between Mexican independence in 1821 and the onset of the Mexican Revolution almost a century later, the central government had a limited but growing role in the provision and regulation of health and medical services. Much authority rested in the hands of local governments, which exercised their powers unevenly. Western allopaths and homoeopaths continued to serve mainly the wealthy classes of criollos and urban Mestizos, although demand for their services, particularly in cities and towns, arose from all sectors.15 Mexico, like Brazil and most of Latin America, followed a French model of medical education well into the twentieth century. With the founding of the Medical Sciences Establishment in 1833—precursor to the national Faculty of Medicine—Mexican medical schools employed French texts and methods, and the medical community discussed and adapted French understandings of the medical themes, discoveries, and practices of the day. The most brilliant and financially able students travelled to Paris for graduate training and returned as leading researchers and authorities. In the late nineteenth century, other influences, including German bacteriology and British, Danish, and North American tropical medicine, gained a foothold, but French ideas and practices retained a primordial role in medicine and social welfare. For example, infant health and welfare services borrowed and adapted heavily from French notions of pueri-culture and eugenics.16 As late as 1928, a prestigious new medical journal entitled Pasteur was founded by the Franco-Mexican Medical Association. Continuing their prior role, Catholic charity hospitals, together with a few new municipal institutions, served the poor, but their concentration in Mexico City and other urban settings, and their untoward reputation, made them a last resort for care. In times of illness or pregnancy, the majority of the urban and rural population relied upon midwives and traditional healers, both male and female, who resided in most communities. Depending on local cultural practices and mestizo or indigenous influences, popular medicine comprised a mix of ideologies and practices, including spiritism, magic,

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and divination, herbalism, hot and cold influences, European allopathy and homoeopathy, evil air healing, and home remedies. In Peru, too, and throughout Latin America, the shortage of regular doctors meant that indigenous, African, Asian, and other immigrant popular healers maintained a large presence.17 Even so, physicians increasingly sought state support and the authority of their medical knowledge to squeeze out competing healing professions, including midwives. By the early twentieth century, titled physicians had gained greater power, acceptance, and wider diffusion among popular sectors.18 Health authorities in Mexico, as elsewhere, had few specific tools at their disposal beyond smallpox vaccination and environmental sanitation. It was principally during major epidemics, such as the 1833 cholera outbreak, that quarantine, fumigation, and isolation were exercised. National legislation expanded state control over hygiene and moral rectitude—for example, an 1864 law mandating inspection of prostitutes—but for the most part public health functioned locally or on an ad hoc basis.19 Appointed sanitary commissions were responsible for monitoring housing conditions, cemetery hygiene, and street and market cleanliness, the latter following from practices of Aztec, Maya, Toltec, and other pre-Columbian cultures. While doctors discussed international medical developments, and various jurisdictions passed legislation, health officials were rarely given the resources or the authority to utilize these tools. By 1900, larger towns—some under popular pressure—began to employ some of the new bacteriologically based public health measures: sanitation, food and milk inspection, diphtheria anti-toxin, and the sporadic collection of mortality statistics, in addition to more traditional functions such as housing reform and enforcement of wet-nurse and prostitute regulations. Public health officials in key ports, most notably Veracruz, were particularly concerned with outbreaks of plague, yellow fever, cholera, and other epidemic diseases,20 wielded substantial implementation powers, and in turn faced considerable popular resistance, as when Rio de Janeiro sought to implement mandatory smallpox vaccination in 1904. Public health in rural Mexico received little routine attention, although certain national campaigns against smallpox and plague were able to reach even remote villages. At a national level, responsibility for public health resided in the Superior Council of Public Health, founded in 1841, but it was only empowered to respond beyond Mexico City upon the request of municipal or regional jurisdictions. An 1891 sanitary code expanded the federal purview to include ports and borders, but it was unable to overturn the decentralized structure of routine public health functions. Still, over time, the purview of the Superior Council of Public Health expanded markedly. From 1885 to 1914, its President was Dr. Eduardo Liceaga, a revered public health leader, who reorganized the Council’s responsibilities to include routine vaccination, the study of epidemics, and urban sanitation, and who oversaw the nation’s first sanitary census. By 1904, the Council had over 6,000 employees, many of whom had received specialized training. The federal government stepped up infectious disease control, organizing a bacteriological laboratory along European lines and administering Pasteur’s anti-rabies vaccine to thousands of people.21 Liceaga was also lauded throughout the Americas for

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overseeing the elimination of yellow fever from Veracruz after a 1903–4 epidemic, employing a combination of sanitary measures, isolation of the sick, disinfection, and petrol-based insecticides. By 1914, even the New York Times had to recognize that the ‘authorities of Mexico have given considerable attention to the study of sanitation and preventative medicine’.22 By no means did the ascendance of allopathy end the widespread presence of a variety of healers or the admixture of medical ideologies and practices in Latin America. In some settings, such as nineteenth-century Colombia, academic doctors’ denigration of a widely followed Andean faith healer exploded into days of street violence. Yet the consolidating power of elite physicians in 1870s Bogotá did not lead to outright elimination of unofficial competitors; instead official doctors and popular healers settled into a more tolerant, long-term pluralism, whereby practices not officially sanctioned were popularized and survived side by side with allopathy.23 Yet the rivalry between professional doctors and ‘traditional’ practitioners may have been overplayed in some history of medicine literature, perhaps because earlier works were written by triumphant doctors and later assessments relied too heavily on officialist sources. In Peru, for example, nineteenth-century medical resentment was channelled into animosity between national and foreign doctors rather than against domestic competitors.24 In Brazil, nineteenth-century attempts to create a hierarchy of legitimate practitioners reinforced the low social status of subaltern healers, including slaves, women, and African healers. Many flourished despite their clandestine status.25 In Costa Rica, traditional healers became a state-sanctioned popular medical corps that served as a practical counterpart to rising physician hegemony. Without a medical school until the mid-twentieth century, Costa Rica had to rely on an insufficient cadre of foreign-trained physicians (often with dubious credentials): experienced indigenous empirics became a viable and much-needed—if at times fiercely contested—source of medical care, especially in rural areas. Because meeting popular demand for medical care made for good politics, the Costa Rican state privileged allopathic physicians without allowing them a medical monopoly. Even the arrival in the late nineteenth century of thousands of indentured Chinese labourers (to build railways) and tens of thousands of Jamaicans and other Afro-Caribbeans (to work on coastal fruit plantations) with their respective healers did not elicit state suppression since they served as (free) district physicians for these labourers.26 In sum, if the nineteenth century brought unprecedented institutional, scientific, and professional legitimacy to trained allopathic practitioners in Latin America, in parallel to Europeans and North Americans, this was only part of the story. The economic and social conditions, cultural diversity, and weaker reach of the state in Latin America meant that a spectrum of popular healers would survive to a far greater extent than in Anglo-European settings, enabling the persistence, hidden or visible, of medical pluralism. By no means did pluralism translate into a single syncretic healing system, but the extensive borrowing back and forth among healing traditions has left footprints into the present.

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Tropical medicine, state-building, and international public health Medical institutionalization was a national effort, yet international public health activities intertwined with Latin American state-building efforts during the late nineteenth and early twentieth centuries. In this context ‘international’ was not an exclusively imperial, North–South category, but also involved regional efforts. Tropical medicine, the sine qua non health enterprise of European (and United States) empires, was also taken up in Latin America on local terms. Even as the Iberian empires were waning, colonial interests in much of the world were consolidating, made ever more lucrative by simultaneous revolutions in industry and raw material extraction, transport, and commerce. However, the colonial enterprise was marred by the threat of so-called tropical diseases that were (often erroneously) associated with the warm and wet climates of many colonial possessions. These ailments interrupted productivity and commerce, felled colonists and labourers, and served as a racialized rationale for imperialism itself, encouraging ‘Northern’ investments in medical research on such ailments as malaria, yellow fever, and onchocerciasis. But tropical medicine was not only of concern to colonial powers. From the 1860s through the 1880s in Salvador da Bahia, a group of dedicated clinician-investigators— subsequently labelled the Tropicalistas—sought to counter European views of the deleterious impact of Brazil’s racial heritage and climate (and implicitly culture) on health. Far from mimicking European research, the Bahian group ‘invented’ a kind of tropical medicine more than two decades before imperial English and French interests staked out the contours of this field. Unlike the physicians of Brazil’s leading medical school in Rio de Janeiro, who absorbed the racialist views of degeneration in the tropics that emanated from Europe, the Bahia school developed its own theory of combined bacteriological and social-environmental factors to explain decaying health—and the prevalence of diseases such as beriberi and hookworm in Brazil. The Tropicalistas’ clinical observations and surgical experimentation on lower-class charity hospital patients furthered their theories of the intertwining of social conditions and parasitological manifestation. The Tropicalistas sought to create not just a Brazilianist medicine, but a Bahian variant—a pointed critique of the more rigid French-derived approach of the Rio school and of government policy on health matters. Yet the Tropicalistas were also heavily influenced by European developments: even as they contested disdainful views on Brazilian inferiority, they desperately sought the legitimacy that European science could grant them.27 In Argentina, Colombia, and other countries, too, local concerns with the economic impact of diseases such as yellow fever and malaria motivated national research that drew from South American as well as European ideas.28 Around this time, a range of regional professional organizations within Latin America began to set common medical research and public health agendas, leading to considerable exchange of ideas and policies.29 Nonetheless, a powerful driver of Latin American tropical medicine and

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international health came from the North. By the late nineteenth century, the United States’ economic presence in Latin America was escalating, accompanied by tropical medicine concerns. The United States’ 1898 war against Spain, although justified by the perennial threat of Cuba’s yellow fever problem wreaking epidemic havoc on US shores, was underscored by American imperialist ambitions and resulted in its acquisition of Spain’ remaining possessions in the Americas and the Pacific.30 The lessons the Americans learned in Cuba, where mosquito-borne diseases killed more troops than firearms, would shape Pan-American health interests for many years to come. Yellow fever had been afflicting ports from Buenos Aires to Halifax since the eighteenth century. The meat and hide economies of Argentina and Uruguay were particularly intent on keeping out yellow fever from Brazil, which might interrupt profitable exports. An 1887 Sanitary Convention signed by the trio detailed quarantine periods for ships bearing cholera, yellow fever, and plague and was in effect for five years before breaking apart. The following year, 1888, the Andean countries of Bolivia, Chile, Ecuador, and Peru signed the Lima Convention. But these efforts were short-lived and circumscribed due to mutual mistrust and poor enforcement. It was a Cuban physician, Carlos Finlay (1833–1915), who set the stage for North American tropical medicine. At the International Sanitary Conference in Washington, DC, in 1878, Finlay proposed that yellow fever was transmitted through the bite of a mosquito. At the time, few believed him. In 1900, Walter Reed (1851–1902) was sent to Havana to head the American Yellow Fever Commission to control an outbreak at the US military garrison. There, Reed and his team confirmed Finlay’s observation through experiments using mosquitoes fed on patients and then unleashed (fatally) on uninfected volunteers. Confirmation of the hardy Aedes aegypti mosquito (then Stegomyia) as the vector for yellow fever motivated large-scale sanitary assaults on mosquito breeding sites, in addition to quarantine of ships in infected ports. In occupied Cuba, US army surgeon William Gorgas (1854–1920) oversaw a series of measures—including daily inspection of homes and yards by legions of sanitarians, mandatory removal or covering of domestic water receptacles, severe fines on property owners for harbouring mosquito larvae, and isolation of every suspected case—that led to a dramatic decline in yellow fever.31 This development would enable the United States to accomplish the longtime imperial dream of building a canal across the Central American isthmus, an effort that French interests had to abandon in the 1880s after spending hundreds of millions of dollars and losing almost 20,000 labourers to malaria and yellow fever. When the United States took over building the canal in 1904, Gorgas became Chief Sanitary Officer. He redoubled the mosquito extermination effort he had led in Havana, with over 4,000 men divided in two brigades, one to eliminate Aedes around human settlements; and the other to clear jungles, drain swamps, and apply oil to Anopheles (the malaria mosquito) breeding sites. Massive use of screens, bednets, quinine, and even piped water for canal workers helped control yellow fever and malaria among workers,32 enabling the canal to be built by 1914. However, these sanitary efforts overlooked—and the US occupation of Panama exacerbated—more pressing endemic problems for local populations, including malnutrition, diarrhoea, and tuberculosis.33

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Ironically, the very completion of the canal raised the peril of new epidemics—such as cholera and plague—due to shorter shipping routes to and from Asia. This heightened the pressure to establish sanitary agreements. In Europe it took more than half a century to transcend inter-imperialist jealousies and resolve concerns over national sovereignty in order to establish a uniform system of disease notification, ship inspection, and maritime sanitation and found the Office International d’Hygiène Publique (Paris, 1907), followed by the League of Nations Health Organization after the First World War. In the Americas, by contrast, international sanitary cooperation was more successful, motivated by immediate menaces. These concerns drove a group of governments in the region to found the Pan American Sanitary Bureau (PASB) in 1902 under the aegis of the US Public Health Service. Soon, almost all Latin American republics were represented at the organization’s quadrennial conferences. The United States was particularly concerned that Latin American countries help draft, and thus comply with, enforceable sanitary codes. The PASB’s early years were devoted to the establishment of region-wide protocols on the reporting and control of epidemic diseases, including yellow fever, plague, and cholera, culminating in a 1924 Sanitary Code, signed by all twenty-one PASB member countries. In its leadership and shaping of activities, the Bureau reflected North American hegemonic interests in Latin America, which covered investments in oil, fruticulture, mining and metallurgy, real estate, railways, banking, and other industries. Indeed, under its self-declared Monroe Doctrine of 1823, the United States had occupied ports and countries across the region whenever it sensed its economic and sanitary interests were threatened. Yet even as the PASB’s agenda remained focused on sanitary and commercial concerns into the 1930s, it began to engage in other activities: sponsoring a widely disseminated public health journal, addressing maternal and child health concerns, and organizing an incipient system of technical cooperation.34 After the Second World War, the PASB would officially become the Americas Office of the World Health Organization (WHO). Just as these efforts were unfolding, a new agency appeared on the scene, one that would profoundly shape international health and influence the transition from European towards US medical influences in the Americas and far beyond. The Rockefeller Foundation (RF) was established in 1913 by oil mogul-philanthropist John D. Rockefeller (1839–1937) ‘to promote the well-being of mankind throughout the world’. After uncovering the important part played by public health in the economic advancement of the US South, the RF created an International Health Board (IHB, later International Health Division or IHD) to promote public health and modernize institutions, befriending dozens of governments around the world and preparing vast regions for investment and increased productivity. By the time of the IHD’s dismantling in 1951, it had operated in over ninety countries, including almost every country in Latin America, with activities to control hookworm, yellow fever, malaria and other diseases, train professionals, and modernize and institutionalize government commitments to public health, all organized and overseen by its own officers stationed in the field. Latin America served as a showcase for RF public health efforts. The RF’s international work began with hookworm campaigns in the Caribbean and Central America,35

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based on its five-year campaign in the US South, in turn drawing from an effort by US army physician Bailey Ashford (1873–1934) in occupied Puerto Rico starting in 1903. Although RF officers believed that controlling hookworm-induced anaemia through a combination of prevention (education and promotion of latrine and shoe use) and treatment (with powerful anti-helminthic drugs) would ignite demand for public health services throughout the Americas, reality was more complicated. Certainly, by the early twentieth century, there was already widespread interest in health services throughout the region, and most governments were pursuing public health institutionalization and a variety of disease-control efforts. Still, most administrations were pleased to take advantage of the steady IHB interest and stream of funding (if in diminishing quantities over time) to build up infrastructure. In no arena were the effects of RF monies as visible as yellow fever, even though, paradoxically, this was a minor cause of death (if a major cause of quarantine and suspension of trade). In 1914, Gorgas, by this time Army Surgeon-General, convinced the RF that the soon-to-be-opened Panama Canal might facilitate the spread of yellow fever. Offering a chance for Rockefeller scientists to showcase their expertise internationally, yellow fever served as an expensive exception to the IHB rule of reasonably priced programmes with a ready cure. Recognition of the global, not just local, implications of yellow fever led to this exception. In 1916, the IHB constituted a Yellow Fever Commission headed by Gorgas to make a reconnaissance trip through South America. Despite observations by Colombian and Brazilian doctors that yellow fever also existed in a sylvan form (known as ‘jungle yellow fever’), the Commission’s travel and subsequent eradication efforts focused on the ‘key centres’ theory—urban locales suspected of being endemic yellow fever loci, initially in the coastal cities of Ecuador, Peru, Colombia, Venezuela, and Brazil, and later Mexico. Following this criterion, the Commission initially found only Guayaquil to harbour yellow fever, and the IHB conducted a two-year disinfection campaign aimed solely at mosquito extermination, despite requests from both Ecuadorian officials and Commissioners to include improvement of water supply and sewage. Adhering to equal single-mindedness, the IHB’s yellow fever campaign moved on to Colombia, Peru, and Central America. The RF finally convinced the Mexican government to accept a campaign in 1921, leading to a massive four-year investment in the country that posed the greatest yellow fever danger to the United States due to its proximity and the volume of migration and trade. In Brazil, epidemic yellow fever was initially believed more problematic in the north than the south, but the disease’s unexpected resurgence in Rio in the late 1920s—combined with the country’s commitment to modernization—resulted in a massive two-decades-long RF–Brazilian government yellow fever campaign that eventually extended into rural areas.36 In addition to disease campaigns, the IHB/D supported development of local and national health departments, and conducted rural health demonstrations and training efforts for both specialists and rank-and-file public health workers. Field officers often complained about the dearth of well-trained medical graduates in Latin America, but the IHB sought to distance itself from medical education concerns, concentrating

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instead on those competent graduates eligible for its own fellowships. Beginning with an RF Medical Sciences Division survey of Brazilian medical schools in 1916, visiting RF experts made periodic assessments of medical education in a variety of Latin American countries.37 They critiqued heavy reliance on clinicians as faculty, overcrowded classrooms, excessive French influence, and an insufficient role for experimental research, but the RF’s involvement in Latin American medical education remained circumscribed until after the Second World War. The only Latin American medical school that the RF deemed worthy of assistance before this time was São Paulo’s, which received a grant of nearly one million dollars in the 1920s to carry out Flexnerian reforms. São Paulo was also the lone Latin American site for an RF school of public health. Still, the RF did not ignore Latin American public health training: it oriented its investment to individuals over institutions. Each year the IHD awarded dozens of public health fellowships to doctors, sanitary engineers, and nurses to study in the United States and return to their home countries to fill key positions. Between 1917 and 1950, 2,500 public health and nursing fellows were sponsored (including approximately 650 US fellows), with some 450 fellows from Latin America and the Caribbean. These fellows managed the relationship between the RF and individual countries, serving as interlocutors, as well as setting up research and graduate institutes to train subsequent generations of public health leaders. The IHD and returned fellows also helped set up incountry training stations for tens of thousands of middle- and lower-rank health workers. This enduring investment in Latin American public health education was considered by many to be the most successful aspect of US–Latin American cooperation. In the early twentieth century, Latin America was a study in contrasts. Elites and a small middle class (and sometimes the military) began to enjoy the fruits of medical and public health progress particularly in urban settings. However, most of the population lived under comparable conditions—and attended similar types of healers—as they had during the nineteenth century or even the colonial period. Most national authorities at least rhetorically supported public health and medical modernization and at times offered patronage for modern research laboratories and new fields such as paediatrics and genetics; some universities were able to self-fund reforms and expansion. Ironically, through this period, Latin American countries were extensively involved in international efforts, with a steady presence at regional and European demographic, health, and medical congresses, but the contrast between state-building rhetoric and medical reality remained large. Outside national capitals and important cities, implementation of even routine sanitary measures was left largely in local hands; some took these responsibilities seriously, but most had few resources and little authority to act beyond responding to epidemics and other crises. In many places, certainly the principal cities, private institutions, Catholic charity, and women’s voluntary organizations filled the gap in public welfare, but funding instability and patronizing criteria for assistance limited their reach. By the interwar period, changes were afoot. Developments in mining, oil, railways, and other industries in Argentina, Brazil, Chile, Mexico, Peru, Venezuela, and elsewhere were accompanied by labour activism; unionized workers (typically excluding the vast

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majority toiling in agriculture) pressed for health benefits and social security. Protection systems proliferated,38 though coverage was uneven and exacerbated inequality in many settings. In countries as diverse as Costa Rica, Brazil, and Colombia, physicians staked a role in state-building efforts, claiming that they played a central part in enhancing not only population health but the nation’s health. In Bolivia, for example, doctors hitched their hopes for greater legitimacy and allopathic professionalization—in a society where Kallawaya and other traditional healers predominated—on their participation in broader discussions of the nation’s trajectory. Yet it was the ill-fated 1930s Chaco War (against Paraguay, and, by proxy, Argentina and foreign oil interests) that served as the turning point in the nation’s political life and in its medical and public health approaches. Working-class mobilization and the formation of new leftist parties, spurred by the war’s soaring death toll, helped end uncontested dominance by elite criollos, ushering in a period of ‘military socialism’ that served as a prelude to Bolivia’s subsequent revolution.39 Indeed, just as biomedicine was rising to its apex, the inextricable political contextualization of health and medical ideas and practices became ever more evident.

The Cold War and the clash between technical and social approaches to health At the end of the Second World War, Latin American countries were poised for further change amidst post-war economic improvements, rising citizen expectations, and growth in public spending for health and social welfare. Even rural populations began gaining health services coverage, if in fits and starts and in stratified form. In 1947, Argentinean physiologist Bernardo Houssay (1887–1971), an RF grantee, became Latin America’s first Nobel laureate in the sciences for his work in endocrinology. His prize simultaneously symbolized a coming-of-age of Latin American medicine and the role of US donors in this process. The support of the RF and other North American foundations for health and medical training, research, and institution-building in Latin America had increased during the war. And, crucially, a massive 1940s infusion of US State Department funding for health and other public infrastructure through the Institute of Inter-American Affairs (a patently propagandistic effort headed by one of the Rockefeller scions to garner support for the Allied Forces) created a palpable North American presence across the region.40 However, as of 1946 a new geopolitical order was in place, and Latin America became one of the most important playing fields for the half-century Cold War rivalry between the US-led Western bloc and the Soviet-led Eastern bloc. Although only just beginning to receive attention by historians, several key themes are apparent.

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One major theme has to do with the role of Soviet models of health and social welfare for Latin America’s developing welfare states. Starting in the 1920s, Soviet accomplishments in social policy had become widely known and admired in Latin America. The 1930s and 1940s saw at least two dozen Latin American medical visitors to the Soviet Union—from Mexico, Argentina, Chile, Cuba, Brazil, Colombia, Venezuela, and Uruguay (and likely elsewhere)—instigated not by Comintern but by Latin Americans themselves. Up to several hundred other Latin American non-physician visitors made their way to the USSR by the 1950s. These observers—some self-funded, others sponsored by their governments—included both the curious and true believers. They carried out surveys of public health service organization, medical schools, and research institutes. Many of them published book-length accounts, which entered into lively debates throughout Latin America around how to shape institutions, services, and citizen rights in the health arena. During the same period, the PASB and the Montevideo-based International Institute for the Protection of Childhood followed Soviet developments closely. Later on, Chilean health policy expert Dr. Benjamin Viel’s 1961 widely disseminated book on socialized medicine compared Chile’s implementation of socialized medicine, a process begun in the late 1930s when Salvador Allende was Minister of Health, to the experiences of Great Britain and the Soviet Union, with the latter’s organizational effectiveness much cited. Of course by the late 1940s, Soviet exemplars were no longer the stuff of innocent debate. Western bloc nations, led by the United States, became increasingly concerned about the appeal of communism to the populations of so-called Third World countries, many of which had growing left-wing political movements by the 1950s. The US response was swift and large. First the Institute of Inter-American Affairs prolonged its funding of hospitals, sanitation systems, and DDT spraying against malaria into the early 1950s, replacing this initiative with an even broader bilateral programme called the International Cooperation Administration (in 1961, it became the US Agency for International Development). Latin America was one of the prime targets of the new US approach to bringing underdeveloped countries into the capitalist fold. Articulated by President Harry Truman in his 1949 inauguration speech, this entailed improving health and productivity and raising living standards through the provision of technical skills, knowledge, and equipment.41 The new health-related United Nations agencies, most notably the WHO and UNICEF, also became embroiled in Cold War ideology. With combating disease deemed a key element in the fight against communism, WHO began efforts against yaws, tuberculosis, and other ailments. Its Global Malaria Eradication Campaign was launched in 1955 and largely financed by the US government. In Mexico, Brazil, and other countries, the campaign displaced existing national approaches, honing in on technical, insecticide-based elimination of malaria’s mosquito vector and sidestepping housing and work conditions and the social context of the disease.42 However, the disease control ideological divide did not fall strictly on East–West lines: after rejoining the WHO in the late 1950s, the Soviets backed smallpox eradication; the campaign did not figure importantly in Latin America, as smallpox

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control had been increasingly achieved through national measures. The showdown between purely technical and socio-technical approaches to health did not take place until the 1970s, when WHO became the stage for a political struggle around primary health care. At the famed international conference held in Alma-Ata, USSR, in 1978 and through the 1980s, Latin America became an important showground for the promise and limits of primary care. By the 1960s, the infrastructure approach was reoriented to a new concern: the control of population size/growth in underdeveloped countries as a means of lessening social and economic pressures that made communism an attractive political option. Once again Latin American countries, which were enjoying lengthening life expectancy yet retained traditional preferences for large families—not to mention growing radical militancy, rapid urbanization, and high unemployment in dangerous proximity to the United States—made them a top priority. Cold War reproductive health programmes even found an unlikely ally in the Catholic Church, whose anti-communism trumped its anti-contraception values in Peru and elsewhere.43 The influence of religious missionaries in Latin American health and hospital care was also renewed in this period. While most missionaries sympathized with North American anti-communism, evangelical medical missionaries, whose presence in the region soared as of the 1970s, did not always fit in neatly with (US) foreign policy goals. At the other end of the political spectrum, advocates of liberation medicine and leftwing Christian medical missionaries (especially from Scandinavia) often worked to counter official anti-communist foreign policy. The Soviet role in Latin American health and medicine, about which little is known, seems to have centred less on infrastructure and in-country programmes than on fellowships and political support (with Cuba being a notable exception). As of the 1960s Moscow’s Patrice Lumumba Friendship University hosted tens of thousands of medical students from the Third World, including large numbers of Latin American students, to train at its Faculty of Medicine. Medical student movements within Latin America, too, engaged with competing communist parties, in the Soviet Union, China, and then Cuba, which established a programme of medical solidarity that sent thousands of its doctors to work overseas. Preliminary evidence suggests that medical radicals in Ecuador, Venezuela, Mexico, and revolutionary movements across the region adroitly played off different parties to the Cold War against one another. The two most prominent Latin American physician radicals were Argentinean Ernesto ‘Che’ Guevara (1928–67), who understood that widespread health gains could be realized only through socialist revolution, not advanced medical technology (leading him to play a pivotal role in Cuba’s 1959 revolution and later in South American movements), and Chilean physician Salvador Allende (1908–73). Father of Latin American social medicine, the socialist Allende rose to prominence in the 1930s as a medical student leader, then health minister for the Popular Front, setting the wheels in motion for Chile’s national health system.44 In 1970, he was elected President, with a platform of nationalization and redistribution, including great attention to occupational and public health; the conservative physicians’ association in Chile was among his fiercest

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opponents. Deposed in a US-backed military coup in 1973, Allende committed suicide, and medical radicals were among the thousands of people who were ‘disappeared’ or forced into exile or underground under dictatorships in Chile, Argentina, Uruguay, Brazil, Paraguay, and elsewhere. Yet even as they faced severe repression, members of radical medical movements remained committed to the principles and policies of social medicine and social justice.45 After the 1979 Sandinista revolution in Nicaragua, thousands of doctors and public health workers from throughout the Americas and beyond joined in the country’s effort to implement primary health care to populations that had been overlooked for centuries, even amidst violent civil war. Brazil’s collective health movement,46 founded during the dictatorship, gave the scaffolding to decades of political struggle to realize a unified national health system and social redistribution measures. The Latin American Social Medicine Association (ALAMES), founded in 1984, strengthened analyses and solidarity at a regional level, supporting national and local political and scholarly efforts to the present.47 Amidst these dramatic developments, shaped (and funded) both by Cold War exigencies and by domestic political pressures for more attention to health and medicine, all Latin American countries enjoyed considerable institutional expansion in public health and medicine. This included the founding of new medical schools across the region and a huge increase in the number of trained medical personnel, the founding of national scientific funding agencies and the renewal of research institutes, the improvement of epidemiological surveillance and public health capacity, and expanded health services coverage. In Cuba and Costa Rica, such developments vastly decreased the inequities in health of previous eras, but in most settings inequalities persisted. In the late 1960s, US health policy analyst Milton Roemer famously noted that in order to determine health care coverage among Latin Americans, one merely needed to ask people’s social class. Just as the region’s dictatorships and repressive regimes were starting to unravel in the 1980s (although conflict continued in parts of Central America and the Andean countries), a new set of challenges emerged that would once again batter health conditions. The oil shocks of the 1970s were an initial boon to oil producers Venezuela and Mexico, but importers were forced into debt, currency devaluation, and soaring inflation. Soon virtually all countries of the region, led by Mexico, began defaulting on their loans, while capital fled. In Latin America, per capita income declined by 7 per cent, consumption by 6 per cent, and investment by 4 per cent between 1980 and 1990. Hyperinflation reached an average of 1500 per cent by 1990. As country after country was ‘rescued’ by the World Bank and the International Monetary Fund, they were compelled to abide by a set of neoliberal, pro-market conditions: these policies included slashing government spending, privatizing social services, deregulating the economy, and liberalizing trade. The 1980s thus became a ‘lost decade’ for health and development, as public health services and institutions drastically deteriorated and health either stagnated or declined, with inequalities once again exacerbated. The end of the Cold War around 1990 once again brought the promise of change.

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Conclusion By the 1990s, political conditions throughout the region had stabilized, but economic woes persisted. Many countries that once had near-universal health systems now had partially or largely privatized health insurance, which drastically reduced access to services. The simplistic health transition theory—postulating a shift from infectious to chronic diseases as countries developed—was clearly disproven in Latin America, with soaring rates of both infectious and chronic diseases. In many settings, under-nutrition was resolved through the industrialization of cheap, energy-dense foods, with negative effects for small-scale farmers and a drastic impact on diabetes, now the leading cause of death in Mexico. Yet certain developments, already present in previous eras, suggest that despite (or perhaps because of) global attention to terrorism and the ‘clash of civilizations’, the region is on more solid footing in health and medical terms. In addition to greater political (and in some places economic) stability, this at least partially stems from both an unprecedented decline in foreign interference in the region and an increase in collaboration across Latin America. One such effort is Cuba’s Latin American School of Medicine (Escuela Latinoamericana de Medicina), founded in 1999 to train thousands of doctors from impoverished backgrounds from throughout the Americas and beyond who return home to serve their communities.48 The Union of South American Nations, or UNASUR, was established in 2008 with the aim of fostering economic integration and within-region development aid. South-to-South cooperation, both within and beyond the region, is now a political priority in Brazil. Moreover, the elections in recent years of progressive governments at the local and national level in Brazil, Uruguay, Paraguay, Argentina, Chile, Venezuela, Honduras, Bolivia, and Ecuador, and other settings (some since elected out of office or deposed), variously led by doctors in the social medicine tradition, have resulted in renewed efforts at universal social and health policies, and even ‘interculturalism’, integrating traditional and Western medicine. As evidenced by the issues touched upon here, the historiography of Latin American medicine and health is complex in geographic, cultural, social, and political terms. While stunted for a long time, the field has enjoyed a renaissance in recent years, making it one of the world’s most dynamic history of medicine literatures.49 Linking contemporary health policy and global health concerns to the writing of history poses certain challenges. Balancing local and national developments with regional and international influences and trends—clearly necessary for comprehensive analysis—is a near conceptual, archival, and temporal nightmare. Should each global health campaign be studied in each setting or can certain trends be generalized from a set of experiences? Comparative work is de rigeur but either deteriorates into superficiality or requires several lifetimes or even a (convenient) marriage of researchers. Establishing an equilibrium among works that rescue local scientific traditions, explore the ‘cultures of health’, address the making of medical and health policies, and track the trajectories of health

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personnel is no mean feat. Getting to know the past, inevitably, is a reflection of the present. Given the exciting, if often terribly destructive, politics of Latin America, its medical and health historiography is poised to be among the world’s most engaging.

Acknowledgements I am grateful to Raúl Necochea for his helpful comments on an earlier draft. My work on this chapter was supported in part by the Canada Research Chairs program.

Notes 1. Guyane, Guiana, and Suriname were colonized by, respectively, France, Britain, and the Netherlands. 2. Francisco Fernández del Castillo, Antología de los escritos histórico-médicos del Doctor F. Fernández del Castillo (México, D.F.: Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), 1982). 3. Robert McCaa, ‘Spanish and Nahuatl Views on Smallpox and Demographic Catastrophe in the Conquest of Mexico’, Journal of Interdisciplinary History 25 (3) (Winter 1995), 397– 431; Noble David Cook, Born to Die: Disease and New World Conquest, 1492–1650 (Cambridge: Cambridge University Press, 1998). 4. Suzanne Austin Alchon, A Pest in the Land: New World Epidemics in a Global Perspective (Albuquerque: University of New Mexico Press, 2003). 5. Joseph W. Bastien, ‘Differences between Kallawaya-Andean and Greek European Humoral Medicine’, Social Science and Medicine 28 (1989), 45–51. 6. Luz María Hernández Sáenz, Learning to Heal: The Medical Profession in Colonial Mexico, 1767–1831 (New York: Peter Lang, 1997). 7. John Tate Lanning, The Royal Protomedicato: The Regulation of the Medical Profession in the Spanish Empire (Durham, NC: Duke University Press, 1985). 8. Ana María Carrillo, ‘Nacimiento y muerte de una profesión: Las parteras tituladas en México’, Dynamis 19 (1999), 167–90. 9. Bernard Ortiz de Montellano, Aztec Medicine, Health and Nutrition (New Brunswick, NJ: Rutgers University Press, 1990). 10. Donald B. Cooper, Epidemic Disease in Mexico City, 1716–1813: An Administrative, Social, and Medical Study (Austin: University of Texas Press, 1965). 11. Andrew Knaut, ‘Yellow Fever and the Late Colonial Public Health Response in the Port of Veracruz’, Hispanic American Historical Review 77 (1997), 619–44. 12. Adrián Carbonetti (ed.), Historias de enfermedad en Córdoba desde la colonia hasta el siglo XX (Córdoba: CONICET, 2007). 13. José Rigau-Pérez, ‘La real expedición filantrópica de la vacuna de viruela: monarquía y modernidad en 1803’, Puerto Rico Health Sciences Journal 23 (3) (2004), 223–31. 14. For further discussion of this, see Chapter 8 by Sanjoy Bhattacharya in this volume.

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15. Claudia Agostoni, ‘Médicos científicos y médicos ilícitos en la Ciudad de México durante el porfiriato’, in Estudios de Historia Moderna y Contemporánea de México (Instituto de Investigaciones Históricas, UNAM, 1999), 13–31. 16. Alexandra Stern, ‘Responsible Mothers and Normal Children: Eugenics, Nationalism, and Welfare in Post-Revolutionary Mexico, 1920–1940’, Journal of Historical Sociology 12 (4) (1999), 369–97. 17. Marcos Cueto, Jorge Lossio, and Carol Pasco (eds), El rastro de la salud en el Perú (Lima: Instituto de Estudios Peruanos, 2009). 18. Ana Cecilia Rodríguez de Romo, ‘Los médicos como Gremio de Poder en el porfiriato’, Boletín Mexicana de Historia y Filosofía de Medicina 5 (2) (2002), 4–9. 19. Rosalina Estrada Urroz,‘Control sanitario o control social: la reglamentación prostibularia en el porfiriato’, Boletín Mexicana de Historia y Filosofía de Medicina 5 (2) (2002), 21–5. 20. José Ronzón, Sanidad y modernización en los puertos del Alto Caribe 1870–1915 (México, DF: Universidad Autónoma Metropolitana/Grupo Editorial Miguel Angel Porrúa, 2004). 21. Ana María Carrillo, ‘Economía, política y salud pública en el México porfiriano, 1876– 1910’, História, Ciências, Saúde—Manguinhos 9 (suppl.) (2002), 67–87. 22. New York Times (26 April 1914). 23. David Sowell, The Tale of Healer Miguel Perdomo Neira: Healing, Ideologies, and Power in the Nineteenth-Century Andes (Wilmington, DE: Scholarly Resources, 2001). 24. Jorge Lossio. ‘British Medicine in the Peruvian Andes: The Travels of Archibald Smith M.D. (1820–1870)’, História, Ciências, Saúde—Manguinhos 13 (4) (2006), 833–50. 25. Marcio de Souza Soares, ‘Cirurgiões Negros: saberes Africanos sobre o corpo e as doenças nas ruas do Rio de Janeiro durante a metade do século XIX’, Locus: Revista de História 8 (2) (2002), 43–58. 26. Steven Palmer, From Popular Medicine to Medical Populism: Doctors, Healers, and Public Power in Costa Rica 1800–1940 (Durham, NC: Duke University Press, 2003). 27. Julyan Peard, Race, Place, and Medicine: The Idea of the Tropics in Nineteenth-Century Brazil (Durham, NC: Duke University Press, 1999). 28. Adriana Alvarez, ‘Malaria and the Emergence of Rural Health in Argentina: An Analysis from the Perspective of International Interaction and Co-operation’, Canadian Bulletin of Medical History 25 (1) (2008), 137–60. 29. Marta de Almeida, ‘Circuito Aberto: idéias e intercâmbios médico-científicos na América Latina nos primórdios do século XX’, História, Ciências, Saúde—Manguinhos 13 (3) (2006), 733–57. 30. Mariola Espinosa, Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930 (Chicago: University of Chicago Press, 2009). 31. Paul Basch, ‘A Historical Perspective on International Health’, Infectious Disease Clinics of North America 5 (1991), 183–96. 32. Paul Sutter, ‘Tropical Conquest and the Rise of the Environmental Management State: The Case of U.S. Sanitary Efforts in Panama’, in Alfred McCoy and Francisco Scarano (eds), Colonial Crucible: Empire in the Making of the Modern American State (Madison: University of Wisconsin Press, 2009), 317–26. 33. David McBride, Missions for Science: U.S. Technology and Medicine in America’s African World (New Brunswick, NJ: Rutgers University Press, 2002). 34. Marcos Cueto, El valor de la salud: una historia de la OPS (Washington, DC: OPS, 2004); Anne-Emanuelle Birn, ‘No More Surprising Than a Broken Pitcher? Maternal and Child

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35. 36. 37.

38.

39. 40. 41. 42.

43. 44. 45.

46. 47. 48. 49.

anne-emanuelle birn Health in the Early Years of the Pan American Health Organization’, Canadian Bulletin of Medical History 19 (1) (2002), 17–46. Steven Palmer, Launching Global Health: The Caribbean Odyssey of the Rockefeller Foundation (Ann Arbor: University of Michigan Press, 2010). Ilana Löwy, Virus, moustiques, et modernité: la fièvre jaune au Brésil entre science et politique (Paris: Éditions des Archives Contemporaines, 2001). Marcos Cueto, ‘Visions of Science and Development: The Rockefeller Foundation and the Latin American Medical Surveys of the 1920s’, in idem (ed.), Missionaries of Science: The Rockefeller Foundation and Latin America (Bloomington: Indiana University Press, 1994), 1–22. Patricio Márquez and Daniel Joly, ‘A Historical Overview of the Ministries of Public Health and the Medical Programs of the Social Security Systems in Latin America’, Journal of Public Health Policy 7 (1986), 378–94. Ann Zulawski, Unequal Cures: Public Health and Political Change in Bolivia, 1900–1950 (Durham, NC: Duke University Press, 2007). André Luiz Vieira de Campos, Políticas internacionais de saúde na era Vargas: o serviço especial de saúde pública, 1942–1960 (Rio de Janeiro: Fiocruz, 2006). Marcos Cueto, ‘International Health, the Early Cold War and Latin America’, Canadian Bulletin of Medical History 25 (1) (2008), 17–41. Marcos Cueto, Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975 (Washington, DC: Woodrow Wilson Center and Johns Hopkins University Press, 2007); Gilberto Hochman, ‘From Autonomy to Partial Alignment: National Malaria Programs in the Time of Global Eradication, Brazil, 1941–1961’, Canadian Bulletin of Medical History 25 (1) (2008), 161–92. Raúl Necochea, ‘Priests and Pills: Catholic Family Planning in Peru, 1967–1976’, Latin American Research Review 43 (2) (2008), 34–56. Maria Eliana Labra, ‘Política e medicina social no Chile: narrativas sobre uma relação difícil’, História, Ciência, Saúde—Manguinhos 7 (1) (2000), 23–46. Howard Waitzkin, Cecilia Iriart, Alfredo Estrada, and Silvia LaMadrid, ‘Social Medicine Then and Now: Lessons from Latin America’, American Journal of Public Health 91 (10) (2001), 1592–1601. Nísia Trindade Lima and José Paranaguá Santana, Saúde coletiva como compromisso: a trajetória da abrasco (Rio de Janeiro: Fiocruz, 2006). Edmundo Granda, ‘Algunas reflexiones a los veinticuatro años de la ALAMES’, Medicina Social 3 (2) (2008), 217–25. H. Michael Erisman, Cuban Medical Internationalism: Origins, Evolution, and Goals (Basingstoke: Palgrave Macmillan, 2009). Anne-Emanuelle Birn and Raúl Necochea, ‘Footprints on the Future: Looking Forward to Latin American Medical History in the Twenty-First Century’, Hispanic American Historical Review 91 (3) (2011), 503–27.

Select Bibliography Armus, Diego (ed.), Entre médicos y curanderos: cultura, historia y enfermedad en la América Latina moderna (Buenos Aires: Ed. Norma, 2002).

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Benchimol, Jaime, Dos micróbios aos mosquitos: febre amarela e a revolução pasteuriana no Brasil (Rio de Janeiro: Fiocruz/UFRJ, 1999). Birn, Anne-Emanuelle, Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (Rochester: University of Rochester Press, 2006). Cueto, Marcos, The Return of Epidemics: Health and Society in Peru during the Twentieth Century (Aldershot: Ashgate, 2001). DiLiscia, María Silvia, Saberes, terapias y prácticas indígenas, populares y científicas en Argentina (1750–1910) (Madrid: Consejo Superior de Investigaciones Científicas, 2003). Hochman, Gilberto, A era do saneamento: as bases da política de saúde pública no Brasil (São Paulo: Hucitec/Anpoc, 2006). Palmer, Steven, From Popular Medicine to Medical Populism: Doctors, Healers, and Public Power in Costa Rica 1800–1940 (Durham, NC: Duke University Press, 2003). Quevedo, Emilio, et al., Café y gusanos, mosquitos y petróleo: el tránsito desde la higiene hacia la medicina tropical y la salud pública en Colombia, 1873–1953 (Bogotá: Universidad Nacional de Colombia, 2004). Stepan, Nancy, The Hour of Eugenics: Race, Gender, and Nation in Latin America (Ithaca: Cornell University Press, 1991). Zárate, C. M. Soledad, Dar a luz en Chile, siglo XIX: De la ‘ciencia de hembra’ a la ciencia obstétrica (Santiago: Ediciones de la Dirección de Bibliotecas, Archivos y Museos, 2007). Zulawski, Ann, Unequal Cures: Public Health and Political Change in Bolivia, 1900–1950 (Durham, NC: Duke University Press, 2007).

chapter 15

h istory of m edici n e i n su b-sa h a r a n a fr ica lyn s chumaker

Africa’s medical traditions exhibit an impressive reach and therapeutic variety. They have spread globally, especially in Latin America and the Caribbean. There they infuse folk medicine and spirit-healing—in Caribbean vodun and in Latin American offshoots of central African lemba and West Africa’s cult of Ogun. The faith healing of North American evangelical churches is also partly based on the medicine of African slaves. African medicine speaks to modern audiences through drumming and dance, and through its broader conception of responsibility for health, implicating the social group, the community, even the state, in the cause and cure of human distress. Many forms of African medical practice emphasize human interdependence with nature and the desire to achieve balance, blending concerns about human health and the health of the environment, a strikingly modern approach in an era of concern about climate change. In Africa, racial, economic, and political factors have determined the availability of medicine and its institutional organization. In the colonial period African healers responded to the criminalization of witchcraft accusations by going underground or presenting a less controversial public face as herbalists. Meanwhile Western and Indian practitioners migrated into higher niches created by racially based medical governance in settler-dominated colonies and early white-ruled nations such as South Africa. Despite the end of colonialism and, later, apartheid, a racially and class-biased political economy still largely determines African health. The colonial legacy of medical experimentation and coercive disease campaigns causes even well-intentioned research and health interventions to trigger negative responses in the twenty-first century, as in South Africa’s debate over the use of anti-retroviral therapy against HIV/AIDS. In Africa’s historiography of medicine, one can perceive two quite different strands: one originating in the discipline of history of medicine, largely confined to the history of Western medicine in Africa; the other originating in African history, dealing with a broader spectrum of medical practices, often delving into the meanings given by Africans to human experiences such as birth and death, well-being and suffering. This

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chapter aims to bring together these two historiographical strands to envisage a future history of medicine that is Africa-centred in its definitions and interests, not just its geographical focus. I begin with African medicine and its historical development. Africa’s so-called ‘traditional medicine’ is actually a dynamic array of healing practices and theories, differing widely across the continent, often incorporating scientific and religious imports. It is the main source of medical treatment for the continent’s population today, as in the past. The second section outlines African medicine’s interaction with world religions, such as Christianity, Islam, and Hinduism, absorbing their healing practices and interpreting their meanings according to African beliefs. The third section discusses colonial medicine, the subject of much recent scholarship. Africa’s experience of colonial medicine has challenged the traditional view of colonial/imperial hegemony— colonial medicine’s impress upon Africa’s peoples was often minimal. Nevertheless, valuable insights have come through study of the variable acceptance of colonial medicine in Africa and how it strengthened or breached the racial cleavages of colonial societies, offered meaning in the face of epidemics, and enforced or ameliorated colonial labour regimes. The fourth section looks at post-colonial medicine, suggesting that ‘contemporary medicine’ is a better way of capturing developments across Africa since the midtwentieth century. Each African country has its own chronology, varying widely in indigenous healing practices, political formation, and economic factors that shape its experiences of medicine. The final section discusses the historiography of medicine in Africa, pointing out its gaps and failures as well as its accomplishments. It directs attention to the underlying conditions of the production of research—funding priorities and publication targets that maintain the dominance of the history of Western medicine as a subject, while marginalizing the medical traditions of Africa and the developing world.

Africa’s medical traditions Historically, European observers have always made assumptions about Africa’s healing practices that placed them outside European definitions of medicine. Explorers called the African healer a ‘witch doctor’, a term that emphasized superstition over knowledge. They also interpreted African medical knowledge as religious in character, with the exception of plant-based remedies, which in the early days of exploration were thought appropriate to the ills that might befall travellers. Even relatively enlightened colonial observers, such as the Southern Rhodesian medical doctor Michael Gelfand, perpetuated similar assumptions when shifting the terminology from ‘witch doctor’ to ‘traditional healer’ or ‘native doctor’. These terms were intended to show respect to the practitioners of ancient medical traditions, which, though unwritten, were based on complex knowledge of African illnesses. By emphasizing unchanging tradition, however, this terminology denied African medicine a past or a future, making it a medicine without history for a ‘people without history’. Once

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exploration gave way to settlement and administration, the story of Western medicine dominated those few colonialist histories that examined medical issues. In the more general discipline of history, the assumption that Africans had no history was remedied by a post-independence, nationalist-driven campaign to produce pre-colonial histories. In the history of medicine, however, there have until recently been few challenges to the picture of traditional healing as a static body of knowledge and traditional healers as preservers of heritage. African healers themselves often use tradition as a strategy to vie for recognition and resources from the post-colonial state or international organizations. Traditional medicine is traditional, however, only insofar as it originated in Africa. Change has been ubiquitous from the beginning and African healers are some of the most enquiring practitioners in the world. Among early practitioners of African medicine were healer-chiefs who enlarged the frontiers of human settlement and, when confronting Africa’s often difficult environments, protected their followers using herbal, social, and spiritual tools. As African frontiers expanded, they constantly revised their understandings of the environment—perhaps one reason why pragmatism and experimentation characterize healers’ work today. This point is missed by scholars who describe traditional medicine as ‘closed’ in contrast to Western science’s supposedly ‘open’ nature, an argument strikingly similar to white colonial racial views.1 The influence of Africa’s healing traditions has been deep and globally far-reaching, despite their failure to attract the popular attention received by Chinese acupuncture or Indian meditation in the West. The diaspora of African medicine is an area in need of much more exploration. While Janzen’s study of the movement of the pre-colonial Lemba cult of affliction from Africa to the New World constitutes a constructive beginning, more recent work on the cultural legacy of central African slaves in the Americas unfortunately subsumes healing within religion.2 Nevertheless, African healing arts prosper when associated with highly successful African religions such as Ogun worship and the Orisha tradition, which have over forty million adherents in West Africa and Latin America, as well as increasing popularity in North America. Many kinds of African healing are based on notions of ‘balance’, with a pharmacopoeia to address imbalances in environments and persons. Hot-cold and wet-dry axes are employed by healers both in areas influenced by Islamic medicine and in types of healing that long predate Islam, while the roots of Hippocratic humoral medicine in Egypt may reflect universal human concerns originating in Africa. In Africa, however, concern about balance transcends the purely medical, such that it might be described as one of the human senses.3 African medical traditions emerged with special reference to environmental survival and to a precarious balance between healing power and political power. Ngoma, the drum, is an ancient symbol of political leadership and of healing ability. Political leadership was closely associated with the ability to keep healthy both a society and the land it utilized, addressing reproductive and productive health. Africa has experienced a relentless process of aridification, a climatic trend making many of its environments an uncertain foundation for human life. The low density of population over much of the continent

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led to deep concerns about fertility. Medicines and protective rituals surrounded every aspect of reproductive life including birth, sex, and the nurturing of women and children. Similarly, land, crops, and animals were protected through medication by healers, invocation of the ancestors, and chiefly rituals. Along with male and female chiefs, women acting as mediums, healers, and central figures in the household often carried particular responsibilities. Healers and ritual specialists diagnosed human and environmental problems and used ritual speech to persuade people to change their behaviour or to invoke spiritual forces. African healers and ritual specialists, today as in the past, are valued because of their ability to contact and influence the forces that control life, death, and nature. In Africa these forces are seen as both good and bad—there is no essential dualism separating good from evil forces. As Sandra T. Barnes has pointed out, in ‘African cosmologies where Ogun is a central figure, destruction and creation are two aspects of a unity that cannot be broken into opposing parts’, and balance, so important in Africa, must be achieved through dynamic pairings, such as protection/destruction.4 Healers are often feared because they might use these forces for anti-social purposes, prospering at the expense of their communities through sorcery. Nevertheless, chiefs are expected to use sorcery to protect their people. Within this context illnesses tend to be divided into three classes: ‘natural’ diseases or ‘diseases of God’, often remedied with herbal treatments; ‘diseases of man’, caused by humans using sorcery to attack others; and illnesses caused by offending ancestral spirits or illnesses that characterize the early stage of becoming a healer, when a healing spirit is making contact. These categories can overlap, or an illness may change category as it develops, with long-term illnesses or illnesses that affect more than one part of the body likely to be blamed on witchcraft or spirit attack. Africa’s ancient and widespread practice of ngoma healing plays a prominent role in contemporary private practice in many parts of Africa. In ngoma healing sessions, complaints of a physical, psychological, or social nature must be voiced in order to bring about healing. The afflicted person joins a community of sufferers and learns to manage the illness through accommodation with the afflicting spirit, sometimes undergoing an apprenticeship that leads to becoming a fully fledged healer. Ngoma has been globally significant since its move to the New World with African slaves. Its contemporary influence on African healing churches is also reflected among their offshoots in America and Europe, while South African sangomas have adapted ngoma for new audiences among the urban black poor and wealthier European and South Asian groups.5 Healing can become a family business passed on from generation to generation, with rural members of the extended family supplying urban healers with the raw materials for plant- and animal-based medicines from rural ‘home’ areas. Trainee healers learn forms of ritual speech that invoke spirits or create new states of being in patients or social groups. Words are used to activate medicines, and the rhythm of drums, too, can act as a kind of speech—particular rhythms call spirits or produce effects in the patient’s body. Singing out the complaint and dancing the affliction are therapeutic practices that call attention to the performative aspects of healing and its languages, and not only in Africa. Becoming a patient in any cultural setting requires a change of social status usually accomplished through ritualistic forms of speech or writing, including the diagnostic

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speech of the Western doctor or the medical ‘papers’ needed to confirm important life transitions (birth and death certificates). Early Western observers of African medicine often failed to appreciate the ritualistic and performative aspects of their own medical language except in obviously religious contexts such as evangelical healing. This led many to mistakenly view African medicine as essentially religious in character.

African medicine and world religions African medicine has been treated as religion because of its intertwining with the continent’s many types of animistic belief. However, there is nothing special in this—religion and medicine also overlap in other parts of the world. When confronting African medicine, however, Islamic reformers and Christian missionaries have solidified its association with religion by interpreting African spirits as Satanic, demanding complete reliance on Christian or Islamic faith healing or the exclusive use of scientific medicine. In some cases, however, the African healing practices they interpret as pagan were based on earlier, now Africanized, Christian or Islamic rituals and spirits. Swahili medicine is a prime example. Research over the past two decades has revealed the African roots of Swahili culture, which thrived in both the interior and the coastal areas of eastern Africa wherever fishing and farming societies intermingled. Traders from the Swahili coast gradually ventured north into Arabia and Persia, taking highstatus Persian names and returning with highly attractive foreign goods. By 800 ce they also brought Islam.6 Interactions between Islam and the earlier spirit therapies of the region can be read ‘archaeologically’ in the layering of different varieties of spirits and their changing status as their healing power increased or diminished with shifts in the political power of the groups with which they were associated. Thus when people in eastern Africa seek explanations for affliction, it is among this historically changing array of spirits that many find meaning, solace, and cures. For example, ‘European’ spirits are no longer relevant after the end of European colonialism, while pagan spirits have recently become less anti-Islamic and Islamic spirits have become more orthodox in response to the increasing status of orthodox Islam. Exceptions are kimasai and mijikenda, both from non-Islamic groups (Maasai and Mijikenda) that enjoy some celebrity in Swahili society. Meanwhile Islamic practitioners vary widely in the theories and practices they employ—humoral concepts and orthodox Islamic medical concepts can be mixed with ideas drawn from witchcraft beliefs, spirit healing, and Western biomedicine. Indeed, earlier types of Islamic medicine included ideas of spirit possession and attack (by majini, shetani) and their cure. Recent types of Islamic medicine reject all forms of spirit explanation and mystical cures.7 Both Islamic and Hindu forms of Indian medicine followed Indian migrants to the continent, for example in South Africa from the 1860s. Indian medicine, both Unani ṭibb (Islamic) and Ayurvedic (Hindu), shares with African medicine humoral ideas about using medicines and diet to achieve balance. Indian shops in cities like Durban historically

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marketed both African and Indian medicines, while itinerant Indian traders carried African and Indian medicines to rural Africans during the decades of segregation. Early Indian migrants sought indigenous African substitutes for Indian plant-based medicines, while African and Indian healers and patients experimented with both types of healing.8 Although Christianity is very old in North Africa and the Horn of Africa, and the central African Kingdom of Kongo converted as early as 1491, most studies of mission medicine focus on the nineteenth- and early-twentieth-century missions that were chiefly responsible for the introduction of scientific medicine and hospital care. These missionaries joined early European traders, hunters, and explorers during the period when disruption caused by the slave trade and early colonial exploitation, such as red rubber extraction, created a context in which Africans were open to new forms of religion and in need of healing. By the late nineteenth and early twentieth centuries, scientific medicine became central to mission activity partly due to its growing status in the metropoles. The preference for scientific medicine among mainstream mission churches also reflected fears that spiritual healing might encourage African spirit beliefs. Initiated by Terence Ranger, research on missionaries’ struggles over the appropriate relationship between healing and scientific medicine have prospered, with the picture extended and complicated by subsequent work.9 For example, Charles Good examined the geographical and technological limitations missionaries faced in Malawi’s difficult terrain, finding that evangelization of the faith and of scientific medical beliefs proceeded unevenly in ways that may have encouraged medical pluralism.10 Other recent work shows how African catechists played key roles in debates over African healing practices,11 while in other cases African nurses and medical auxiliaries actively translated mission medicine using local African ritual and secular language, fitting it to African conceptual systems in ways that white mission staff neither understood nor controlled.12 Although mission medicine proved popular in most parts of Africa—often more popular than government services where they existed—some Africans broke from mainstream churches, founding African churches that practised faith healing. These addressed the failure of mission ritual and mission medicine to deal with the full range of spiritual and physical afflictions recognized by Africans, especially witchcraft. Schism over the role of Christianity in healing continues today, for example in the case of Archbishop Milingo in Zambia, whose use of faith healing at a time of crisis in the country’s health and economy in the 1980s proved so controversial that the Catholic Church removed him from the country.13

Colonial medicine Megan Vaughan’s Curing Their Ills in 1991 was a milestone in the understanding of Western medicine in Africa.14 It juxtaposed government medical and psychiatric services, disease campaigns, mission medicine, and tropical medicine, revealing the diverse settings and relationships within which they acted. Vaughan’s book contributed to a

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growing picture of medicine as a morally complex activity, revising earlier critiques that it was simply an instrument of colonial power. A chapter on mission medicine in John and Jean Comaroff ’s Of Revelation and Revolution also contributed to this new understanding, portraying the ambiguities of mission medical practices that brought different people together, cutting across the racial cleavages of colonial society.15 Initially, during colonial conquest, tropical medicine focused on European health. Its greatest successes came with the ‘scramble for Africa’s diseases’, resulting in good careers for metropolitan researchers but mixed benefits for African populations exposed both to disease and to early colonial experiments in preventive and curative measures. Racially based theories of disease sometimes labelled ‘native’ populations as reservoirs of infection—as in the case of malaria among humans (believed to be caught from too close proximity to African women and children), or sleeping sickness among animals (tolerated by Africa’s wild antelope but deadly to European cattle). Nevertheless, the argument that a ‘sanitation syndrome’ was the chief cause of segregation in colonial cities has been disputed—it was one among many factors, social, economic, and political— and timing was of the essence, racial medical theories having the most impact when epidemics coincided with crucial phases of city development. Racial segregation in medical institutions has also proved to be more complex than initially thought, with much good work being done on South Africa.16 The influence of tropical medicine declined in the 1920s as attention shifted to the health of indigenous peoples and to diseases that stood in the way of development. This included a public health focus on water-borne diseases, industrial diseases like tuberculosis, and maternity services and child health. Malaria remained important because colonial doctors began to recognize its impact on Africans, especially on children’s survival. The shift to African health spurred government-funded military-style ‘disease campaigns’, focused on diseases like sleeping sickness, yaws, and syphilis. Africans sometimes found mass medical examination and treatment stigmatizing or causing fears of infertility when vaccination targeted children. However, campaigns could also be seen as cleansing, on the model of pre-colonial witchcraft cleansing by chiefs and later colonial witch-cleansing movements.17 Early studies of syphilis and tuberculosis in Africans bolstered arguments for white rule and segregation by supporting theories of African physical inferiority or promiscuity or dangerous cultural practices, often distracting from economic conditions that were more important.18 Similar theories would emerge in scientific discourses during the HIV/AIDS epidemic.19 Colonial industries also organized medical services for workers, which varied enormously in quality. Mining companies typically sent ill or disabled workers ‘home’ to rural areas instead of providing treatment, one of the reasons for the rapid spread of tuberculosis to rural areas in the colonial period. Historians of the political economy of disease have examined migration to mines and plantations in considerable depth on a regional basis. Despite its potential as an approach for understanding global interconnections in disease history, however, little work has followed up Burke and Richardson’s pioneering study of links between nineteenth-century phthisis, tin-mining, and Cornish labour migration to South Africa.20

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The tiny specialism of colonial and imperial psychology, meanwhile, has become something of a boom industry.21 Colonial psychologists, few in number and often embedded in settler societies, developed theories of the ‘African mind’ that justified European control, projecting colonial violence onto Africans or using Freudian interpretations of African child development to explain the failure of Africans to embrace European work regimes.22 Others medicalized African dissent or explained it as ‘mass hysteria’.23 But others used Freudian psychoanalysis to question simplistic racial or cultural views of African subjectivity.24 Scholars have also examined institutionalization along models familiar from European studies of madness.25 Meanwhile recent work has revealed how limited was the reach of psychiatry; Julie Parle explores the meanings of mental affliction in the family and community, as well as the asylum, enriching the analysis by including witchcraft and suicide.26 An important gap in this literature is the history of cross-cultural psychology during the 1960s, unexplored despite its impact on attempts to develop culturally sensitive forms of psychological testing for education, employment, and clinical treatment in the crucial period around African independence.

Post-colonial medicine? After independence new African states saw medicine as central to modern nationhood, increasing funds for hospitals and medical schools, which, like big dam projects, reflected modernity and national pride. Primary care services were extended into rural areas to make up for colonial shortfalls, displacing mission medicine. Africanization of health care staff, already begun in the late colonial period, intensified after independence even in countries that already supported a substantial number of Western-trained African doctors; since the late nineteenth century African doctors had worked in Nigeria and South Africa, while Malawi’s first president, Hastings Kamuzu Banda, had worked as a doctor in Scotland. In most places the first African nurses, usually male, had been trained at colonial mission stations, but after independence training increasingly moved to urban nursing colleges.27 The politics of race, gender, and class that shaped the careers of female nurses working in hospitals could be enormously complex, with South Africa perhaps best represented in the scholarship.28 Despite the lack of publicity for their work in the West, postcolonial African doctors have been involved in crucial stages of disease research on the continent, pinpointing the emergence of East Africa’s HIV epidemic, for example.29 The term ‘contemporary’ may be more appropriate than ‘post-colonial’ for capturing the history of national experiences on the continent since the mid-twentieth century. Ethiopia, for example, experienced colonialism only briefly and nurtured medical traditions that have yet to be given full historical treatment.30 South Africa was independent well before 1950 (though for the black majority, white rule arguably shared much with direct European colonialism). ‘Post-colonial’ also diverts attention from continuities with the colonial period—in Africanization programmes, for example. It also obscures the similarities of today’s health crises to the overlapping demographic and

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environmental crises of the early colonial period caused by wars, harsh labour regimes, and resource pillaging. Today, neoliberal reforms, resource wars, and global trade conditions have ravaged African health care services and harmed natural resources and small-scale agricultural production on which health ultimately depends. As in the period around World War I, these conditions exacerbate epidemics even when they do not directly cause them. Market reforms in the 1990s, for example, demanded the introduction of fees for health care in the midst of Africa’s emerging HIV epidemic. Thus it is vital to focus on economic change as well as political breakpoints when devising a chronology of medicine for Africa. Colonial law transformed the organization of traditional practitioners, forcing them out of the political sphere and privatizing their practice, but colonial commerce at the same time transformed traditional medicine’s pharmacopoeia, its packaging, and marketing. Today, neoliberalism has been similarly transformative. Market reforms and the reorganization of health care services have stimulated the expansion of traditional medicine and the blossoming of mass production and larger trading networks. This has been accompanied by a brisk informal trade in Western pharmaceuticals and medical procedures, due to the breakdown of government regulation and the pressures on hospital staff salaries that lead the highly qualified to seek jobs abroad while others sell hospital drugs to supplement shrinking incomes or set up independent, unregulated surgeries. South Africa’s quite different political trajectory, with its early transition to white rule and jockeying for power between different white factions, is a case that also defies easy post-colonial interpretations. The country’s racially based distribution of health care reached its peak under apartheid, when medical researchers led the world in heart transplant technology, an achievement built on the wealth of resources spent on medical care for the white minority, and neglect of the African majority. Majority rule has not, however, ended the uneven distribution of medical benefits. Class differences, largely aligned with race, determine access and quality of health care. The weight of this history is still felt in the twenty-first century, for example, in South Africa’s debate over the use of antiretroviral therapy against HIV/AIDS. This debate is not only framed by questions about the trustworthiness of Western scientific understandings of HIV but also about how state funding for health care should be fairly distributed—into relatively expensive treatment for HIV or into primary care and prevention.

Global asymmetries and inconvenient histories The writing of history of medicine in Africa began with an imperial/colonial bias: medical historians, including colonial doctors, assumed medicine was a civilizing force pitted against the suffering and superstition intrinsic to Africa. They told a story of Western medicine’s triumphs over disease already familiar from Europe’s own ‘great man’

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medical history. When Prins evaluated the historiography in 1989, he applauded new work that engaged with African concerns, but despite some successes large areas of African experience remain invisible.31 Today the priorities of the broader discipline of history of medicine still limit what research can be done in Africa, making it easier to study Western medicine at the expense of the many other topics that are possible in this richly diverse continent. Nevertheless, new work is eroding disciplinary and methodological boundaries and demonstrating how history of medicine could strengthen its ethical and intellectual reach by making Africa and other marginal regions of the world more central to its project. What Prins applauded was a generation of African-studies-trained scholars who placed medicine in its historical and social contexts. This was exemplified by the work of John Janzen and Steven Feierman, who used a mix of anthropological and historical approaches to African health-seeking in plural medical contexts.32 Similarly, Harriet Ngubane and Murray Last and Gordon Chavunduka provided a sociological analysis and some of the first historical accounts of African medicine, although Last and Chavunduka’s contribution was framed by the Western concept of professionalization.33 These works established a methodological dialogue between anthropology and history that has characterized the best of the subsequent literature. Prins also highlighted work focused on the complex interactions among Africa’s peoples, pathogens, and politics, led by John Ford’s study of colonial sleeping sickness campaigns.34 This has resulted in a still growing literature on environment and health, and regional epidemic histories.35 Prins also noted work in the political economy of health and disease, especially Randall Packard’s study of tuberculosis in South Africa.36 In light of Roy Porter’s groundbreaking articles on the role of the patient in Britain, Prins also expected future historians of Africa to produce more patient-centred histories. This hope has been only partially fulfilled. Another key assessment of medicine’s African historiography was Megan Vaughan’s 1994 discussion of problems of methodology and approach—in particular, the failure to question Western medicine’s ‘theory of itself ’ as an objective, culturally neutral process.37 At the level of practice, she argued, Western medicine may not be all that different from other types of healing, amenable to the same approaches applied to African healers. Colonial mission medicine proved a tempting example. Subsequently scholars looked at mission doctors and nurses in detail, examining their assumptions about African patients and their conflicts with healers. Nurses, both European and African, as well as medical auxiliaries, are often central to the interactions between Western and African healing practices described in these studies. Work that ventures out from the mission enclave to capture wider African perspectives is rare, however. Hunt’s study of birth in the Congo sets a high standard. She begins with pre-colonial African understandings of birth and its dangers, and its unexpected metaphorical role in the making of masculinity through boys’ initiation rituals. This provides a firm basis for examining the subsequent medicalization of birth by colonial missions and government and its impact on Congolese notions of citizenship and the state.38 Also innovative is Good’s study of the Universities’ Mission to Central Africa in Malawi, capturing the mission’s interactions

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with African communities through its use of technologies of transport, as well as medicine.39 Vaughan also called for more studies of medical research, as did Maureen Malowany, the latter emphasizing the importance of detailed examination of what medical researchers think and how they experiment and promote their findings.40 Today numerous scholars are examining trajectories of discovery and intervention in disease history, with notable work in veterinary medicine, which has received little attention in the past.41 Recent work on medical research stations also breaks new ground by employing the memories of African researchers as a window on scientific practices.42 More does indeed need to be known about how medical researchers think, but the most rewarding approach situates researchers squarely within African environments, cultures, and histories, and in the social and moral worlds of the many others around them who also intervene in health and illness. However, it is striking that there is not an equally urgent call for research on changes in how African healers think and experiment. Few scholars have examined ‘experimental moments’ in African medicine, with the exception of Karen Flint’s work on how South African healers effectively marketed traditional medicines in competition with European and Asian pharmacists.43 Few studies centre on African healing history; most look at ‘responses to’ Western medicine, allowing Western medicine to set the agenda. While it is true that ethnographies exist for a wide range of African healing traditions they are rarely historicized, with the exception of Harry West’s Kupilikula, Feierman’s Peasant Intellectuals, and Janzen’s lemba study and his ongoing work on ngoma.44 Indeed, topics such as these—the changing medical and political uses of healing language and practice or the deep history of healing traditions—would be unlikely to attract funding specific to history of medicine today. The reasons are partly structural, relating to funding processes, and partly methodological and disciplinary. Like Prins, Vaughan assumed good historical scholarship in Africa must sometimes employ anthropological as well as historical methods. She encouraged ‘inconsistency’ in defining subject-matter and choosing approach, rather than following the standard ‘academic division of labour’. Debates about approach are truly academic, however, when funding is decided along rigid methodological and disciplinary lines. Lack of adequate funding harms African history of medicine, making it difficult to study languages (where language is the key to deeper understanding), to do oral history respectfully with adequate follow-up, to complete archival work under difficult conditions, and to use ethnography when appropriate to the topic. Both African and non-African scholars are disadvantaged by a lack of funding, leaving Africa marginalized and missing the opportunity for the larger discipline of history of medicine to produce globally centred (rather than Euro-American-centred) histories. A glance at the ultimate product of funding decisions—publication in history of medicine journals—reveals the effects of disciplinary and methodological restrictions. Few articles about sub-Saharan Africa appear in Medical History, Bulletin of the History of Medicine, Social History of Medicine, and the history of science journals that publish history of medicine—fewer than those about other regional traditions such as China or India,

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which have a stronger archival base. In recent years, Social History of Medicine has outstripped others in its coverage of Africa (and China and India), indicating that the absence of coverage in other journals is not simply because scholars prefer region-specific audiences. Nevertheless, the African articles published in Social History of Medicine almost exclusively deal with Western medicine. Africa’s indigenous medicine is left without a history in the very journals in which debates about the discipline’s appropriate topics, boundaries, and divisions of labour could most productively take place. Not every topic requires ethnographic methods, but many important areas cannot be explored if scholars are not free to choose the best tools for the job. As Hunt has observed of Africa, ‘No continent has achieved more interesting fusions of history and anthropology.’45 If funders demand that disciplinary boundaries be strictly observed, African scholarship is disadvantaged by its interdisciplinary strengths. Western origins also shape the idea of history that animates history of medicine. For example, the history of a Graeco-Roman physician such as Galen is seen as central to Western medicine. Funding is less available for the history of prominent African healers because they are not included in this lineage, except where they interact with colonial doctors. Such healers have had a profound impact on African health, on resistance and accommodation to colonialism, and on African responses to epidemics. This is not to say that Africa needs more histories of ‘great medical men’ (or women), but the history of healers is an important part of a larger project to uncover the understandings possessed by African ‘intellectual communities’, of which we have so far only obtained ‘tantalising hints’.46 Concentration on alternative medical or healing lineages and intellectual communities could help history of medicine to escape the limitations of its Western origins. The discipline has yet to embrace a truly post-colonial approach—one that not only deals with colonial medicine and its aftermath in the former colonies but also situates medical developments in the former metropoles within a wider post-colonial world. Medicine ‘at home’ in England or France, for example, has been changed by the colonial experience, too. More research on African categories of experience could also lead to a vibrant combination of African studies with approaches from history of science, technology, and medicine. A similar cross-fertilization of ideas and methods took place in the 1980s and early 1990s when Africanist and European anthropological and historical approaches joined to bring about advances in history.47 An area where cross-fertilization has begun is the ‘history of the body’, which since the 1990s has become a special focus in the history of medicine. This approach combines methods from anthropology and cultural history to uncover the history of change in human bodies, in embodied experiences, and in the materiality of therapeutics. Historians of the body employ historical ethnography—an approach that, for example, enriches Ruth Harris’s book on healing and medicine at the Catholic shrine of Lourdes in France.48 Many historical topics also require observing traces of bodily history found in posture and movement today. For Africa, one of the few works comparable to Harris’s achievement is Didier Fassin’s When Bodies Remember, a contemporary history of South African responses to HIV/AIDS and controversies over anti-retroviral drugs.49

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Fassin examines the politics of medicine across all levels of South African society, from the disadvantaged rural poor to the Treatment Action Campaign to (former president) Thabo Mbeki, his medical advisers and their embrace of so-called ‘AIDS denialism’. Despite dealing extensively with the science of HIV/AIDS, Fassin transcends the usual analytical framework of history of science that has characterized much previous work on AIDS. He instead finds the roots of contemporary positions, including AIDS denialism, in the historically embodied experiences of apartheid violence, South Africa’s racist health care system, and Africa’s wider history of medical and physical exploitation. He does this through eliciting individual and collective memory and observing embodied behaviour over a significant period of South Africa’s recent history.50 Fassin is an anthropologist but this book is one of the finest examples of historical insight in South African history of medicine. Perhaps anthropologists enjoy greater freedom to be ‘inconsistent’ in approach than do historians of medicine—though Fassin also struggled with issues of funding and lack of interest in the French academic context.51 History of the body as an approach also focuses our attention on the patient. Recent work in this area includes Julie Livingston’s Debility and the Moral Imagination in Botswana. She uses the term ‘debility’ to raise her work above the standard literature on the ‘history of disability’, which has been limited by the Western definition of disability and focused mainly on the professional specialisms that address disability. In contrast, Livingston transforms definitional and cultural differences into an opportunity to achieve deeper understanding of how healing and caring are done by a wide range of people. She does not simply examine specific Western or Tswana diseases or conditions, but deals instead with ‘misfortune’ and its African meanings. In her work ethnography is key to historical insight: even the most sensitive oral historical methods cannot tease out the unacknowledged or inarticulate aspects of suffering, healing, or care-giving and the ‘diverse expressions of morality’ that infuse them. Thus her work pays attention to ‘posture, gossip, complaining, bathing, hiding, nursing, diagnostics, proverbs, giftgiving, etc’.52 Another way to bring African perspectives and categories into history of medicine is to examine realms of human experience that are not simply defined as medical. Lynn Thomas’s Politics of the Womb, for example, deals with the history of ‘procreation’ in Kenya, examining its medical, political, and other meanings.53 Thomas’s study is also an ‘externalist’ account that helps to balance the dominance, in history of medicine, of ‘internalist’ accounts that focus narrowly on medical researchers’ worlds or the internal development of particular medical specialisms or institutions. Luise White’s work on ‘vampire stories’ also challenges scholars to start with African categories of experience; medical technologies appear among an array of frightening objects and activities Africans use to describe colonial relationships.54 If applied to current health care issues— for example, the so-called ‘moral panics’ sometimes sparked by the introduction of antiretrovirals or child vaccination programmes—such approaches aid in the critique of current medical intervention practices. Vaughan’s recent work on the history of death in Africa is another project that puts medicine in its place among a range of other types of knowledge and practice. In some parts of Africa rituals of death are intimately linked to

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rituals of life and/or the protection of the vulnerable against illness or sorcery—something not easily grasped if analysis is limited by Western medical definitions.55 Prins was interested in ‘what happens to our images of both Africans and of disease when we move from a doctor-centred to a patient-centred account’.56 Feiermans’s early work on kin-based decision-making in a plural medical context led the way, while groundbreaking new work includes Eric Silla’s examination of leprosy from the patient’s perspective.57 More work also needs to be done on historical situations in which the patient is the doctor—whether using home remedies, family and neighbourly health knowledge, or self-treatment. Self-treatment occurs in all historical periods and helps to trace continuities across colonial/post-colonial divisions, as well as turning attention away from the misleading dualism of Western versus traditional medicine. People who self-treat rely upon locally available herbal resources and the changing pharmacopoeia—Western, African, Islamic, or other—that they find in markets, formal and informal.58 A focus on the history of home remedies often necessitates the use of anthropological approaches, however, as pointed out by Vivienne Lo for China.59 Finally, a return to the political economy of disease is needed. Little has changed since 1997 when Shula Marks raised concerns about the ‘silencing of class issues’ in scholarship on colonial medicine.60 The political economy approach is especially needed at the global level. Of recent work, Jock McCulloch has placed South African miners and communities within a global distribution of the social costs of production of asbestos, while Randall Packard’s global biography of malaria challenges us to do a more relevant kind of history, willing to challenge the truisms of economics and development policy.61 We also must place Africa in a global political economy of health care and medical research, to seek the historical roots of global inequalities in the distribution of medical benefits versus medical risks. Studies are needed of how the discourse of Africa as ‘virgin medical territory’ is re-created in each historical period since the beginning of colonial medical research and how this has contributed to Africa’s attractiveness as a site for ‘pharmaceutical colonialism’.62

Conclusion Only through a restructuring of funding priorities will new approaches flourish and expand the global vision of the discipline. Funding, particularly in Britain, is in need of reform: as Richard Bowring observed, ‘the funding mechanism has for many years been exerting undue influence on the kind of research we do. It generates a form of selfcensorship, whereby we aim for short-term benefit and ignore the truly valuable.’63 Grant funding and the pressures of research assessment targets have created a situation that resembles private sector sub-contracting—those who promise more in less time with less money win the contract. Scholars should pursue research that reflects their skills and interests, but when scholars choose Africa they find that many topics cannot be properly researched within one- to three-year timetables. Timetables should reflect the needs of

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particular topics and the time required for effective use of appropriate methods. Today’s increasingly competitive funding arena has engendered not innovation but the reluctance of scholars to pursue less convenient histories—histories that require non-European language-learning, oral history, and ethnography. This ensures continuation of current global asymmetries in the discipline—the dominance of histories of Western medicine and the marginality of Africa and other regions of the developing world. We need new funding structures that stimulate work on under-represented regions, such as Africa, and under-represented topics, such as patient-centred histories. This is a situation that demands inspired, committed work, not only in Africa but also in the wealthy nations that primarily fund historical research, challenging funding priorities and research timetables. The historical roots of Africa’s health problems must be tackled through listening and observing with respect and taking time to appreciate the perspectives of informants—necessary for good history in contexts of suffering and misfortune, as well as in contexts of hope and healing, which we find in abundance in Africa. This history is inconvenient for universities striving to meet targets and for funders and department heads who want an immediately tangible ‘product’. However, these limitations must not be allowed to create a partiality of research vision that colludes with other global inequalities to make Africa’s health problems seem intractable. Africa’s ill-health is the product of social, political, and economic causes that we can confront with the strength of historical understanding and long-term, committed scholarship.

Acknowledgements I thank the editor, Mark Jackson, and all those who kindly read and commented on this chapter in manuscript, especially Steven Feierman and Henrika Kuklick.

Notes 1. Robin Horton, ‘African Traditional Thought and Western Science’, Part I, Africa 37 (1) (1967), 50–71; and Part II, Africa 37 (2) (1967), 155–87. 2. John M. Janzen, Lemba, 1650–1930: A Drum of Affliction in Africa and the New World (New York; Garland, 1982); Linda M Heywood (ed.), Central Africans and Cultural Transformations in the American Diaspora (Cambridge: Cambridge University Press, 2002). 3. Kathryn Linn Geurts, Culture and the Senses: Bodily Ways of Knowing in an African Community (Berkeley: University of California Press, 2002). 4. Sandra T. Barnes, ‘The Many Faces of Ogun’, in eadem (ed.), Africa’s Ogun: Old World and New (Bloomington: Indiana University Press, 1997), 1–27, at 17–19. 5. John M. Janzen, Ngoma: Discourses of Healing in Central and Southern Africa (Berkeley: University of California Press, 1992); Rijk van Dijk, Ria Reis, and Marja Spierenburg (eds), The Quest for Fruition through Ngoma: The Political Aspects of Healing in Southern Africa (Oxford: James Currey, 2000).

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6. Thomas Spear, ‘Early Swahili History Reconsidered’, International Journal of African Historical Studies 33 (2) (2000), 257–90. 7. Linda Giles, ‘Sociocultural Change and Spirit Possession on the Swahili Coast of East Africa’, Anthropological Quarterly 68 (2) (1995), 89–106. 8. Karen Flint, ‘Indian-African Encounters: Polyculturalism and African Therapeutics in Natal, South Africa, 1886–1950s’, Journal of Southern African Studies (JSAS) 32 (2) (2006), 367–85. 9. Terence Ranger, ‘Godly Medicine: The Ambiguities of Medical Mission in Southeast Tanzania, 1900–1945’, Social Science and Medicine 15 (3) (1981), 261–77. 10. Charles M. Good, The Steamer Parish: The Rise and Fall of Missionary Medicine on an African Frontier (Chicago: University of Chicago Press, 2004). 11. Markku Hokkanen, ‘Quests for Health and Contests for Meaning: African Church Leaders and Scottish Missionaries in the Early Twentieth Century Presbyterian Church in Northern Malawi’, JSAS 33 (4) (2007), 733–50. 12. Walima T. Kalusa, ‘Language, Medical Auxiliaries, and the Re-interpretation of Missionary Medicine in Colonial Mwinilunga, Zambia, 1922–51’, Journal of Eastern African Studies 1 (1) (2007), 57–78; Walima T. Kalusa, ‘Disease and the Remaking of Missionary Medicine in Colonial Northwestern Zambia: A Case of Mwinilunga Disrict, 1902–1964’, PhD thesis, Johns Hopkins University, 2003. 13. Gerrie ter Haar, Spirit of Africa: The Healing Ministry of Archbishop Milingo of Zambia (London: Hurst, 1992). 14. Megan Vaughan, Curing their Ills: Colonial Power and African Illness (Cambridge: Polity Press, 1991). 15. John and Jean Comaroff, Of Revelation and Revolution, vol. 2 (Chicago: University of Chicago Press, 1997). 16. Harriet Deacon, ‘Racial Segregation and Medical Discourse in Nineteenth Century Cape Town’, JSAS 22 (2) (1996), 287–308. 17. Bryan Callahan, ‘ “Veni, VD, Vici”?: Reassessing the Ila Syphilis Epidemic’, JSAS 23 (3) (1997), 421–40. 18. Karen Jochelson, The Colour of Disease: Syphilis and Racism in South Africa, 1880–1950 (Basingstoke: Palgrave, 2001). 19. Suzette Heald, ‘The Power of Sex: Some Reflections on the Caldwells’ “African Sexuality” Thesis’, Africa 65 (4) (1995), 489–505. 20. Gillian Burke and Peter Richardson, ‘The Profits of Death: A Comparative Study of Miners’ Phthisis in Cornwall and the Transvaal, 1876–1918’, JSAS 4 (2) (1978), 147–71. 21. Andrew Scull, review of Sloane Mahone and Megan Vaughan (eds), Psychiatry and Empire (Basingstoke: Palgrave Macmillan, 2007), Social History of Medicine 21 (2) (2008), 411–13. 22. Jock McCulloch, Colonial Psychiatry and the African Mind (Cambridge: Cambridge University Press, 1995). 23. Sloane Mahone, ‘The Psychology of Rebellion: Colonial Medical Responses to Dissent in British East Africa’, Journal of African History, 47 (2) (2006), 241–58. 24. Saul Dubow, ‘Wulf Sachs’s Black Hamlet: A Case of Psychic “Vivisection”?’, African Affairs 92 (1993), 519–56. 25. Jonathan Sadowsky, Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria (Berkeley: University of California Press, 1999); Lynette Jackson, Surfacing Up: Psychiatry and Social Order in Colonial Zimbabwe, 1908–1968 (Ithaca: Cornell University Press, 2005).

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26. Julie Parle, States of Mind: Searching for Mental Health in Natal and Zululand, 1868–1918 (Scottsville, South Africa: University of Kwazulu-Natal Press, 2007). 27. Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999). 28. Shula Marks, Divided Sisterhood: Race, Class and Gender in the South African Nursing Profession (Basingstoke: St Martin’s Press, 1994); Simonne Horwitz, ‘Black Nurses in White: Exploring Young Women’s Entry into the Nursing Profession at Baragwanath Hospital, Soweto, 1948–1980’, Social History of Medicine 20 (1) (2007), 131–46. 29. John Iliffe, East African Doctors: A History of the Modern Profession (Cambridge: Cambridge University Press, 1998). 30. Jacques Mercier, Art that Heals: Image as Medicine in Ethiopia (New York: Museum for African Art, 1997); Richard Pankhurst, Introduction to the Medical History of Ethiopia (Trenton, NJ: Red Sea Press, 1990) 31. Gwyn Prins, ‘But What was the Disease? The Present State of Health and Healing in African Studies’, Past and Present 124 (1) (1989), 159–79. 32. John M. Janzen, The Quest for Therapy in Lower Zaire (Berkeley: University of California Press, 1978); idem, Lemba; Steven Feierman, ‘Struggles for Control: The Social Roots of Health and Healing in Modern Africa’, African Studies Review 28 (2–3) (1985), 73–147; Feierman and Janzen (eds), The Social Basis of Health and Healing in Africa (Berkeley: University of California Press, 1992). 33. Harriet Ngubane, Body and Mind in Zulu Medicine (New York: Academic Press, 1977); Murray Last and Gordon Chavunduka, Professionalisation of African Medicine (Manchester: Manchester University Press, 1986). 34. John Ford, The Role of the Trypanosomiases in African Ecology: A Study of the Tsetse Fly Problem (Oxford: Clarendon Press, 1971). 35. Maryinez Lyons, The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900–1940 (Cambridge: Cambridge University Press, 1992); Helen Tilley, ‘Ecologies of Complexity: Tropical Environments, African Trypanosomiasis, and the Science of Disease Control in British Colonial Africa, 1900–1940’, Osiris 19, 2nd series (2004), 21–38. HIV/AIDS has increasingly dominated epidemic histories since the mid-1990s—see John Iliffe, The African AIDS Epidemic: A History (Oxford: James Currey, 2006); Shula Marks, ‘Science, Social Science and Pseudo-Science in the HIV/ AIDS Debate in Southern Africa’, Journal of Southern African Studies 33 (4) (2007), 861–74; Terence Ranger and Paul Slack (eds), Epidemics and Ideas (Cambridge: Cambridge University Press, 1992); Howard Phillips, ‘Black October’: The Impact of the Spanish Influenza Epidemic of 1918 on South Africa (Pretoria: The Government Printer, 1990). 36. Randall Packard, White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa (Berkeley: University of California Press, 1989). 37. Megan Vaughan, ‘Healing and Curing: Issues in the Social History and Anthropology of Medicine in Africa’, Social History of Medicine 7 (2) (1994), 283–95. 38. Hunt, Colonial Lexicon, 27–79. 39. Good, Steamer Parish. 40. Maureen Malowany, ‘Unfinished Agendas: Writing the History of Medicine of SubSaharan Africa’, African Affairs, 99 (2000), 325–49. 41. William Beinart, Karen Brown, and Daniel Gilfoyle, ‘Experts and Expertise in Colonial Africa Reconsidered: Science and the Interpenetration of Knowledge’, African Affairs 108

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42.

43.

44.

45. 46.

47. 48. 49. 50. 51. 52. 53. 54. 55.

56. 57. 58.

59. 60.

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(432) (2009), 413–33. For further discussion of animal and human medicine, see Chapter 31 by Robert Kirk and Michael Worboys in this volume. See chapters by Wenzel Geissler, Lyn Schumaker, and Gulliaume Lachenal in Wenzel Geissler and Catherine Molyneux (eds), Evidence, Ethos and Experiment: The Anthropology and History of Medical Research in Africa (Oxford: Berghahn, 2011). Karen Flint, Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948 (Athens: Ohio University Press, 2008), 128–57; and Teresa Barnes’s review of Anne Digby, Diversity and Division in Medicine: Health Care in South Africa from the 1800s (Oxford: Peter Lang, 2006), Journal of African History 50 (3) (2009), 449–51. Steven Feierman, Peasant Intellectuals: Anthropology and History in Tanzania (Madison: University of Wisconsin Press, 1990); Harry G West, Kupilikula: Governance and the Invisible Realm in Mozambique (Chicago: University of Chicago Press, 2005). Nancy Rose Hunt, ‘Whither African History?’, History Workshop Journal 66 (1) (2008), 259–65, at 259. Shula Marks quoting from Luise White’s ‘ “They Could Make their Victims Dull”: Genders and Genres, Fantasies and Cures in Colonial Southern Uganda’, American Historical Review 100 (5) (1995), 1379–402, at 1395, in Marks, ‘What is Colonial about Colonial Medicine? And What has Happened to Imperialism and Health?’, Social History of Medicine 10 (2) (1997), 205–19, at 215. Eric Hobsbawm and Terence Ranger (eds), The Invention of Tradition (Cambridge: Cambridge University Press, 1983). Ruth Harris, Lourdes: Body and Spirit in the Secular Age (London: Penguin Books, 1999). Didier Fassin, When Bodies Remember: Experiences and Politics of AIDS in South Africa (Berkeley: University of California Press, 2007). See Virginia Berridge’s review of Fassin’s book in Journal of Contemporary History 44 (1) (2009), 153–5. Fassin, When Bodies Remember, xi–xii. Julie Livingston, Debility and the Moral Imagination in Botswana (Bloomington: Indiana University Press, 2005), 20. Lynn Thomas, Politics of the Womb: Women, Reproduction, and the State in Kenya (Berkeley: University of California Press, 2003). Luise White, Speaking with Vampires: Rumor and History in Colonial Africa (Berkeley: University of California Press, 2000). Rebekah Lee and Megan Vaughan, ‘Death and Dying in the History of Africa since 1800’, Journal of African History 49 (2008), 341–59; Isak Niehaus, ‘Death before Dying: Understanding AIDS Stigma in the South African Lowveld’, Journal of Southern African Studies 33 (4) (2007), 845–60. Prins, ‘But What was the Disease?’, 161. Eric Silla, People Are Not the Same: Leprosy and Identity in Twentieth-Century Mali (Oxford: James Currey, 1998). Anne Digby, ‘Self-Medication and the Trade in Medicine within a Multi-Ethnic Context: A Case Study of South Africa from the Mid-Nineteenth to Mid-Twentieth Centuries’, Social History of Medicine 18 (3) (2005), 439–57. Vivienne Lo, ‘But Is It [History of] Medicine? Twenty Years in the History of the Healing Arts of China’, Social History of Medicine 22 (2) (2009), 283–303. Marks, ‘What is Colonial about Colonial Medicine?’, 215–16.

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61. Jock McCulloch, Asbestos Blues: Labour, Capital, Physicians and the State in South Africa (Oxford: James Currey, 2002); Randall Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007). 62. Adriana Petryna, When Experiments Travel: Clinical Trials and the Global Search for Human Subjects (Princeton: Princeton University Press, 2009); Tanya Lyons,‘Globalisation, Failed States and Pharmaceutical Colonialism in Africa’, Australasian Review of African Studies 30 (2) (2009), 68–85. 63. Richard Bowring, letter, London Review of Books (11 March 2010), 4.

Select Bibliography Bell, Heather, Frontiers of Medicine in Anglo-Egyptian Sudan, 1899–1940 (Oxford: Oxford University Press, 1999). Echenberg, Myron, Black Death, White Medicine: Bubonic Plague and the Politics of Public Health in Colonial Senegal, 1914–1945 (Oxford: James Currey, 2001). Fassin, Didier, When Bodies Remember: Experiences and Politics of AIDS in South Africa (Berkeley: University of California Press, 2007). Flint, Karen, Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948 (Athens: Ohio University Press, 2008). Good, Charles M., The Steamer Parish: The Rise and Fall of Missionary Medicine on an African Frontier (Chicago: University of Chicago Press, 2004). Hunt, Nancy Rose, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999). Livingston, Julie, Debility and the Moral Imagination in Botswana (Bloomington: Indiana University Press, 2005), Parle, Julie, States of Mind: Searching for Mental Health in Natal and Zululand, 1868–1918 (Scottsville, South Africa: University of Kwazulu-Natal Press, 2007). Schumaker, Lyn, Diana Jeater, and Tracy Luedke (eds), ‘Histories of Healing: Past and Present Medical Practices in Africa and the Diaspora’, Journal of Southern African Studies, Special Issue, 33 (4) (2007). Silla, Eric, People Are Not the Same: Leprosy and Identity in Twentieth-Century Mali (Oxford: James Currey, 1998). Thomas, Lynn, Politics of the Womb: Women, Reproduction, and the State in Kenya (Berkeley: University of California Press, 2003).

chapter 16

m edici n e a n d col on i a lism i n sou th a si a si nce 1500 m ark h arrison

In 1500, the region that we now know as South Asia was enjoying a period of relative stability. Although Vasco da Gama had reached the south-western coast of India two years previously it would be another decade before the Portuguese established a colonial presence in Goa. The Indian subcontinent was divided into numerous polities, none of which were especially powerful, and it was only after 1526 that it would gradually become united under the Mughal Empire—an entity that eventually controlled all but the southern tip of the subcontinent. Mughal rule added another layer to the cosmopolitan culture of South Asia but it did not alter radically the nature of medical practice there. By the time of the Mughal invasion, ‘Islamic’ medicine or Unani ṭibb had been established in parts of India for several centuries, having been introduced by Arab traders and earlier invaders from the north-west. Over time, it absorbed elements of local medical traditions, principally Ayurveda, which was practised largely, but not exclusively, by Hindu physicians called vaidyas or vaids. It was an ancient tradition passed on partly by word of mouth and partly through Sanskrit texts; its centre of gravity lay in the north of the subcontinent but its practitioners were widely disseminated. In parts of southern India, the dominant medical tradition—also largely a Hindu tradition—was siddha, a form of medicine influenced by tantrism and alchemy, which made extensive use of chemical therapies. All these traditions viewed disease as an imbalance of bodily substances (like humours in the Western tradition), which they saw as existing in dynamic equilibrium with the environment.1 This enabled elements of all three traditions to be blended together and patients often visited practitioners of a different ethnicity from their own. However, in the first instance, most Indians would have sought medical advice or treatment from a diverse array of local healers and wise-folk, ranging from holy men and shamanic healers to bone-setters and persons skilled in the use of medicinal plants.2 In bazaars, practitioners also had access to a wide range of drugs, some of which came from as far afield as China and East Africa.

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Over the next five centuries this medical culture began to change, albeit slowly, as the influence of European medical practitioners, traders, and governors began to be felt. As more and more of India fell under the sway of colonial rule, the pace of change accelerated as Indian traditions began to respond to the challenges posed by a different medical system. From the nineteenth century, the consolidation of the British colonial state also brought the first medical interventions in the lives of its Indian subjects: sometimes in the form of preventive medicine, sometimes through curative facilities such as hospitals and dispensaries. As exposure to Western medicine increased, many Indians began to avail themselves of opportunities to acquire knowledge of it, and by 1900, thousands were graduating in Western medicine every year. By the end of British rule in 1947, Western medicine was firmly established as the dominant form of medicine and would remain so after independence. But Indian medical traditions did not die. Most adapted to the presence of another medical system and some even began to expand overseas, following the diaspora that began under colonial rule and which has continued ever since. These centuries of change have captured the imagination of many historians who have attempted variously to chart the histories of Indian medical traditions and assess the interventions made by the colonial powers. There is now an extensive corpus of literature on all these aspects of the subcontinent’s recent medical history and the task of reviewing it is daunting. Nevertheless, this chapter attempts to sketch some of the main themes in historical scholarship, focusing particularly on those issues that have generated the most controversy. It cannot pretend to be an exhaustive survey but it may suffice to provide a flavour of the debate, some indication of where scholarship is heading, and where much remains to be done.

Rival traditions? The impact of colonial rule on Indian medical traditions has been the subject of considerable debate. Until recently it was assumed that the advent of formal colonial rule had had a negative, if not disastrous, impact upon Indian medical traditions. During the sixteenth and seventeenth centuries there were attempts to proscribe forms of unlicensed medical practice in Portuguese territories, for example. However, it is now generally recognized that these efforts failed; and not surprisingly, in view of the practical difficulties involved. Official attempts to constrain local practitioners were also undermined by Portuguese physicians who often sought experience with Indians before they were employed in European hospitals. Nearly all visitors agreed that Indians possessed superior knowledge of how to treat local diseases,3 and it was for this reason that they were employed as assistants in most of the hospitals erected for the treatment of Europeans.4 However, respect for Indian medical knowledge ought not to be exaggerated. With the exception of some missionary scholars based in the Danish settlement of Tranquebar,5 most Europeans had a confused idea of Indian medicine and often conflated different types of practitioner.6 Insofar as admiration for Indian medicine existed,

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it lauded the therapeutic efficacy of Indian treatments rather than the principles underlying them.7 By the early nineteenth century, even this grudging respect had largely evaporated. The Native Medical Institution, founded in Calcutta in 1822 to teach elements of both European and Indian medicine, was wound up in 1835. From that point on, the state supported institutions for the teaching of Western medicine only, the first being the Calcutta Medical College, founded in 1835. This transition is said to be symptomatic of a more general shift in opinion, away from an ‘Orientalist’ form of governance—in which the form and even some of the content of Indian traditions was recognized by the state—to the vigorous imposition of Western values upon Indian society.8 Following this onslaught, it was assumed that Indian medical traditions went into a steep decline that did not begin to reverse until the devolution of political power in 1919. These reforms enabled Indians to make policy on health and medicine for the first time, albeit only at provincial levels of government.9 Few historians deny that the early nineteenth century saw a shift in official attitudes towards Indian medicine but the withdrawal of state funding from the Native Medical Institution did not have such a negative impact as once imagined. Rather, it appears that Indian traditions retained much of their popularity throughout the nineteenth century and underwent a period of critical self-examination that left them reinvigorated and resurgent. This renewal often took place in the context of religious revivalism and political nationalism, being stimulated only partly by the challenge posed by Western medicine.10 The main impetus for the reform of Unani medicine, for example, may have emanated from a long-established Arabic tradition of scientism rather than competition with or emulation of Western practitioners.11 Either way, Ayurvedic and Unani medicine remained important cultural forces throughout the nineteenth century and this was sometimes implicitly recognized by the state during periods of emergency, such as epidemics, when it was forced to rely on traditional practitioners to augment government services.12 The process by which Indian traditions of medicine adapted to the challenges and opportunities of colonial modernity has been examined in recent works by Guy Attewell and Kavita Sivaramakrishnan. Both stress the vital role of print media in the dissemination of new medical ideas, including Western notions of health and disease, which were gradually being incorporated into Indian medical traditions. Like some other scholars, they emphasize the porous nature of Indian medicine and the lack of any distinct alignment with religious belief. Many practitioners of Ayurveda, for example, were to be found among Sikhs as well as Hindus, while Hindus also practised Unani ṭibb. The patient base of these different medical traditions was equally broad and inclusive.13 Again, both studies reinforce the emerging picture of gradual adaptation rather than radical change. While provincial administrations began to recognize Indian medicine after 1919, and while it was supported by central government after 1947, there was no need actively to revive Indian medical traditions because they were already thriving. They had positioned themselves skilfully to take advantage of their difference from Western medicine by emphasizing their links with spiritual traditions and their advocacy of holistic as

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opposed to reductive treatments.14 Yet, practitioners of traditional medicine also adopted elements from Western medicine to inspire greater confidence among patients. As a result, some Ayurvedic and Unani practitioners began to train in colleges rather than serve apprenticeships, to acquire knowledge of Western physiology and anatomy, and to treat patients in hospitals as well as in their homes. Like practitioners of Western medicine, they also began to obtain their drugs from the booming Indian pharmaceutical industry and many lost the ability to identify these plants in the wild.15 Although Western drugs—especially those produced by Western pharmaceutical companies— were aggressively marketed in India, Ayurvedic medicines and other traditional preparations were mass-produced and mass-marketed too.16 All this had begun to happen before independence from Britain, suggesting that while colonial rule affected the development of these medical traditions, it did not have a powerfully detrimental effect.

Epidemics and colonial politics For much of the 1980s and 1990s, the historiography of medicine in India was dominated by the study of epidemics. At first, attention focused upon the great mortality caused by malaria and more episodically by diseases such as smallpox, cholera, and plague.17 But later on, historians turned their attention to the political and social ramifications of epidemics, drawing their inspiration from historians of Europe and America who used them as ‘windows’ through which to observe societies under strain.18 It was assumed that epidemics brought to the surface social tensions that were otherwise masked by a veneer of normality. By the mid-1980s the historiography of epidemics acquired an additional dimension as members of the Subaltern Studies collective began to take an interest in the popular protests provoked by state responses to epidemics. The original aim of the collective was similar to that of E. P. Thomson and other British social historians, in that it hoped to rescue the voice of India’s downtrodden masses from the ‘condescension of posterity’.19 Up to that point, colonial historiography had been content either to criticize British rule or to record the history of India’s liberation struggle. However, in doing so, attention remained firmly fixed upon the role of elites, such as leaders of the Indian National Congress. The important role of workers and peasants in the liberation struggle was largely overlooked. Drawing on the work of the Italian Marxist Antonio Gramsci, David Arnold set out to write the history of epidemics from the viewpoint of these largely forgotten peoples. He showed how traumatic events such as the spread of cholera from its place of origin in deltaic Bengal were viewed by many peasants as symptomatic of the political chaos and dislocation caused by territorial annexation.20 However, Arnold’s chief interest was in social responses to measures devised by the colonial government to control the spread of epidemic diseases. This led him to analyse not only cholera epidemics but the day-today work involved in the prevention of smallpox through vaccination and, later, attempts to contain the plague epidemic that erupted in western India in 1896.21 Arnold’s work on

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smallpox made much of the invasive and secular character of vaccination and the fact that it was apparently rejected by many Indians on cultural grounds. His study of the response to the arrival of plague also highlighted the tendency of the authorities to ignore Indian cultural sensibilities. This was perhaps most evident in policies such as the forcible medical inspection of women, and the violation of caste and other religious taboos through enforced hospitalization and segregation. These draconian measures elicited a powerful backlash, recalling the trauma of the Indian Mutiny/Rebellion and marking the beginning of so-called ‘extremist’ nationalism. Although Arnold examined the responses of the colonial state and the role played by nationalist politicians, he emphasized the spontaneous nature of much popular protest: the mass flight from cities such as Bombay, the strikes of mill-hands and factory workers, and attacks on hospitals and government officials. In doing so, he made use of both official reports—reading them ‘against the grain’ in an attempt to weed out colonial bias—and vernacular newspapers, accessible in translated extracts in reports on the ‘native press’. However, these sources rarely provide the historian with the authentic voice of subaltern protest; after all, most peasants and factory workers were illiterate and unable even to write their name. More importantly, perhaps, they do not allow us to generalize about the nature of ‘Indian’ responses to epidemic disease. As Raj Chandavarkar pointed out in a perceptive essay on plague panics in India, there was no unified or homogeneous response to either the disease or the measures designed to contain it.22 He argued that the popular backlash provoked by plague measures had less to do with the state impinging upon ‘popular culture’ than with the peculiar political and economic circumstances surrounding the epidemic. Resistance to measures such as hospitalization was not simply a function of caste or other religious sensibilities but reflected the fact that Indians, like many Western peoples, preferred to remain with their families and that they were suspicious of the intentions of medical practitioners. Epidemics are rarely unified events and various communities experience them differently. This is true in any society but especially, perhaps, in a vast, predominantly rural country like British India. Nor do epidemics necessarily tell us much about the nature of social relations. They are, by definition, atypical events and may give a misleading impression of the degree of hostility towards the state or Western medicine. Unfortunately, we still lack the longue durée histories that might enable us to draw reliable conclusions about attitudes to state medicine and outbreaks of epidemic disease. We simply do not know how Indian communities adjusted to the endemic or frequent epidemic presence of cholera or plague, for example. This is not a problem unique to the historiography of South Asia, however. It is perhaps unrealistic to expect a major monograph on the history of cholera in British India when none exists for Great Britain itself, at least beyond the first epidemic of 1831–2. But the historiography of epidemics has not perished altogether. Although there is no grand history of cholera or plague in the making, there is growing interest in the relationship between epidemics and religious pilgrimages: both Hindu pilgrimages within India and the annual pilgrimage of Muslims to Mecca and Medina. These were intensely problematic issues for the colonial state but it was forced to grapple with them under the

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spotlight of international concern. The International Sanitary Conference convened at Constantinople in 1866 established India as the source of the cholera pandemics that had recently afflicted Europe and much of the rest of the world.23 The immediate cause of the 1865–6 pandemic was an outbreak of cholera in Mecca, which was widely attributed to pilgrims from India. However, large gatherings of pilgrims at religious fairs in India, such as the melas held at Hardwar and other sacred sites on the River Ganges, were also seen as hubs from which cholera radiated throughout India. As such, there was an expectation that the British government would take measures to reduce the likelihood of epidemics, including the improvement of sanitation at pilgrimage sites and, if necessary, the proscription of pilgrimage altogether. However, intervention in such a sensitive area carried great risks and the colonial authorities, centrally and locally, aimed to strike a balance between appeasing international opinion and maintaining social order.24 Arrangements for the sanitary regulation of pilgrimage inevitably produced a great deal of friction; nevertheless, it appears that sanitary measures at such gatherings led gradually to the acceptance of Western notions of hygiene.25 After 1866, the way in which the British authorities dealt with epidemic disease was scrutinized internationally and other countries took measures to reduce the risk of infection from India. The quarantines imposed by European countries and international boards of health at Constantinople and Alexandria are therefore of great interest to historians who wish to view British India in the wider context of international politics. Most agree on the vital importance of quarantine in Anglo-Indian medical policy and that the state did its best to minimize disruption of trade and communication with the rest of the world. It is also agreed that official medical doctrine in India reflected this overriding consideration, maintaining that cholera was rarely, if ever, a contagious disease. However, while most studies emphasize the determination of the Government of India to remove or reduce quarantine,26 Sheldon Watts claims that it did so largely at the behest of the government in London. In his view, London was determined to see the removal or relaxation of quarantine at all costs.27 However, recent work confirms that the Anglo-Indian government had an agenda in Central and Southern Asia that was sometimes at odds with that of the home government, and that this manifested itself clearly in debates over quarantine.28

Sanitary reform: a lost opportunity? The dominance of quarantine in official deliberations sometimes overshadowed the more mundane aspects of public health policy. However, in the mid-Victorian period, sanitary reform was becoming more important, being regarded as the touchstone of an enlightened and civilized state. Many British medical officers and civil servants therefore believed that it was their duty to bestow the benefits of sanitation upon the population of India, seeking to replicate the process of reform in Britain itself. By the end of the century, it was widely assumed that imperial rule meant sanitary progress, and so the

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official narrative stood for the remainder of British rule.29 But supporters of the liberation struggle often took a different view. While some progress was acknowledged, it was held that the vast majority of the Indian population, particularly in rural areas, obtained few medical or sanitary benefits from British rule.30 After 1947, it also became clear that many of the grandiose claims made about the Empire’s sanitary achievements were unsupportable.31 Historians differ in their explanations of these generally accepted limitations. In one of the first major interventions of the post-independence period, Hugh Tinker asserted that sanitary reform flourished only in those areas where effective control of public health remained in British hands. Starting with the transfer of power to elected municipalities in the 1870s, devolution, in his view, had generally been disastrous for public health because most Indian politicians took little interest in such matters.32 At the opposite extreme are those who support Radhika Ramasubban’s contention that sanitary improvement was confined only to small enclaves of the colonial state and that the British ‘lost the historic opportunity for initiating sanitary reform’. In her view, they were not simply indifferent to the health of the Indian population but actively scuttled all initiatives put forward by Indians.33 This position has subsequently been endorsed by many scholars, among them David Arnold and Anil Kumar.34 Arnold, for example, blames the Government of India for devolving responsibility for day-to-day sanitary work on municipal authorities that were poorly financed and inexperienced.35 Other historians have also pointed to the weakness of newly formed municipalities such as those in the jute-manufacturing towns of Bengal.36 It is generally acknowledged that colonial health policy privileged the needs of Europeans and key sectors of Indian society—such as the army—upon which the state depended for its security. However, some historians believe that it is impossible to account for the limitations of public health solely by reference to the priorities of the colonial government. Roger Jeffery, for example, has pointed to the difficulties of implementing sanitary improvements in a vast country with limited resources. He remains unconvinced that there was ‘any conceivable alternative’ to the policies developed under British rule.37 The funding of sanitary reform depended to some extent on different systems of taxation. Local authorities in parts of India such as the North West Provinces and Oudh (present-day Uttar Pradesh), which raised revenue using trade taxes (octroi), were particularly vulnerable to fluctuating economic conditions and tended to have significantly lower levels of public health funding than provinces, such as Bengal, which depended mainly on property taxes.38 The narrow, property-owning franchise in Indian municipalities also meant that landed interests often acted as a drag on sanitary reform.39 But by which criteria ought colonial public health measures to be judged? It is all very well to write of the limitations of colonial health policy but is there a ‘normal’ process of modernization against which developments in India can be judged? Can we criticize the colonial administration for devolving much of the responsibility for public health to local governments when the same bodies—rather than central government—bore the responsibility for public health in Britain? There was certainly much debate in both

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official and nationalist circles about the relative balance of responsibilities between local, provincial, and central government. However, until the emergence of socialized health care in the Soviet Union, very few people advocated State involvement in public health of the kind envisaged by Ramasubban. Indeed, attitudes towards State intervention in public health shifted markedly over time but not necessarily in the same direction. As colonial rule drew to a close, the State began to fracture in ways that meant that responsibility was shared more widely than previously. As the case of smallpox vaccination shows, it was spread across a variety of agencies from central government down to local and district boards, in the middle of which were the new provincial health departments, some of which were headed by Indians after 1919. Although alliances were often formed between different agencies at times of crisis, they tended to work against each other in a way that compounded some of the scientific and technical problems that reduced the effectiveness of vaccination.40 As Sanjoy Bhattacharya has argued, these complex structures and the tensions they engendered persisted well beyond 1947. The impetus behind the vaccination programme increased with the involvement of the World Health Organization from the 1960s, but the disjointed nature of public health intervention remained until the disease was eradicated from India in 1975.41 The measures taken against smallpox reveal the difficulty of reconciling contrary tendencies in South Asia’s transition to modernity. The desire for devolution complicated the response to a problem for which there appeared to be a technical solution. But in the case of malaria—the greatest cause of mortality in South Asia year on year—it became increasingly evident that there was no simple technical fix. Although the discovery of the mosquito vector of malaria parasites raised great hopes at the beginning of the twentieth century, experiments with mosquito control in even limited areas proved disappointing.42 The same was true of prophylaxis with quinine, although it proved valuable in the treatment of malaria. According to some historians, the blame for the failure of malaria control rests firmly with the colonial government. Malaria ranked low on the government’s list of priorities: unlike plague or cholera, it did not stir civil unrest or compromise trade and communications with the rest of the world. Above all, perhaps, any effective response to the problem was negated by the huge cost entailed by measures such as drainage and the fact that they were likely to conflict with other priorities such as irrigation for agricultural development.43 Most historians acknowledge the limited progress made during the period of British rule,44 but in the absence of any detailed, large-scale study of malaria in British India we ought to be wary of generalization. Even the first half of the twentieth century, which has formed the subject of most studies of malaria in South Asia, is thinly covered. We currently lack studies of epidemic areas such as Sindh, for example, and while excellent work has been done examining the links between malaria epidemics, famine, and irrigation,45 we need more detailed research on the relationship between malaria and agricultural development. The political aspects of the problem have also been largely ignored, except insofar as they were bound up with the international health movement from the 1930s.46 Further work on anti-malaria policies is required before we will be able to evaluate the government’s response to the problem of malaria or its role in aggravating it.

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The case of malaria reminds us of how much basic work remains to be done on the history of public health in India. Indeed, colonial health policies have often been considered without regard to their impact on mortality or morbidity. In the 1970s and 1980s, Ira Klein, Tim Dyson, and others began to analyse mortality trends in British India but few historians have taken their work further.47 Judith Richell’s detailed study of disease and demography in Burma is one of the few exceptions.48 She concludes that public health made little impact upon mortality, an observation borne out by a recent study of smallpox vaccination in the province, which shows that the practical difficulties of implementing vaccination in Burma far exceeded those encountered in the presidencies of British India.49 This raises the questions of how far Richell’s conclusions apply to other provinces where mortality began to decline in the 1920s. In a chapter devoted to the subject in a recent monograph, the historian Sumit Guha has argued that India’s ‘mortality transition’ was due primarily to better weather conditions. In his view, climatic stability enabled the Indian population to maintain a ‘moderate’ level of malnutrition, whereas the more unstable weather patterns of previous decades had resulted in severe famines.50 He claims that the oscillation between adequate nutrition and severe malnutrition was a major factor in the severe mortality crises of the later nineteenth century.51 Other recent studies also attribute mortality decline, in part, to better nutrition,52 but cannot be regarded as conclusive. Indeed, if the persistent debate over mortality decline in Western countries is anything to go by the controversy over what happened in India has only just begun. Some aspects of India’s epidemiological history have scarcely been examined at all, particularly certain chronic diseases that became significant causes of death in the course of the twentieth century. From the turn of the century, crusading public health workers began to highlight the growing problem of respiratory diseases in Indian towns, particularly among textile mill workers.53 Neither the epidemiological nor the political ramifications of tuberculosis and other respiratory diseases have been examined in detail, nor have other diseases hitherto regarded as confined to Western civilization. David Arnold’s recent study of diabetes stands as a notable exception,54 but we need similar studies of cancer, for example, which became increasingly prominent in epidemiological studies from the 1940s.55

Controlling bodies and minds Since the late 1980s many historians have commented on medicine’s use as a tool of social control and its hegemonic role in establishing the dominance of Western culture. David Arnold can reasonably be said to have inaugurated this trend, blending together insights from Foucault and Gramsci.56 Since then, scholarship has highlighted the medical elements within racial theories, for example,57 and the role of medical institutions in expressing and consolidating colonial power. But institutions such as leprosy colonies and lunatic asylums arguably did little to cement colonial rule. While there was a

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growing desire to confine ‘lepers’ from the 1890s, in most parts of India (Orissa excepted) relatively few people were incarcerated in leprosaria.58 Lunatic asylums also aimed to incarcerate disruptive elements but the numbers involved were again negligible.59 Nor were these institutions particularly successful in moulding their inmates to fit colonial expectations of civilized life. Disciplinary regimes, dietaries, and treatments often had to be negotiated with inmates, forcing concessions from the authorities.60 Indeed, colonial authority was often diluted by the fact that many of these institutions were run on a day-to-day basis by Indian staff with agendas very different from those of their British superiors.61 Medical authority was imposed with rather more success in India’s jails, however. From the 1830s, jails were increasingly subject to medical regulation as part of a broader programme of prison reform and in response to the staggering death rate among inmates. Indeed, jails offered tremendous scope for clinical experimentation and trials with new vaccines, trials that contributed substantially to the legitimacy of key medical technologies such as inoculation against plague.62 One medical institution that stands out from all the others is the so-called ‘lock hospital’, the sole purpose of which was to cure women suspected of having ‘venereal diseases’. These ‘hospitals’ were established in or adjacent to military cantonments from the late eighteenth century, the aim being to reduce the likelihood that soldiers would be infected and thus rendered unfit for duty. It would appear that the Indian lock hospitals were among the first of their kind and that they established a precedent later built upon in Britain, with the passage of the controversial Contagious Diseases Acts in the 1860s. Similar legislation was passed in India shortly afterwards, placing on a firmer foundation the measures that had existed on and off in cantonments for many decades. The Acts were repealed in the 1880s following protests from women’s groups and Christians offended by state-sanctioned immorality, but in India the use of lock hospitals continued under the guise of other legislation, marking a continuity of attitudes and approaches throughout the period of British rule.63 The impact of the Contagious Diseases Acts in the Indian context is open to question, however. Some claim that the Acts bore lightly on the communities they affected and were not especially oppressive,64 while others stress the opportunities that the Acts presented to subordinate staff for extortion and bribery.65 Either way, lock hospitals were untypical of British medical institutions, even custodial ones, in that most hospitals were intended to reach out to Indian communities in a way that demonstrated the benevolence of colonial rulers. Hospitals and dispensaries for the poor (attended predominantly by untouchables and Indian Christians) were said to highlight the apparent indifference of Indian elites by contrast with the humane ethos of a Christian power. The same was true of hospitals for women. A ‘lying-in’ or maternity hospital was established in Madras in the 1840s and quickly became a model of its kind, contrasting with the harshness with which Hindu women (particularly widows) were treated by their own communities.66 Together with the growth of municipal and company-owned dispensaries from the 1830s, such institutions were part of a concerted effort to ‘civilize’ the Indian people. Their foundation coincided with public health initiatives that had a similar aim, notably the extension of vaccination against smallpox.67

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Medicine can thus be said to have a played a major role in a new vision of colonialism that evolved in the final years of Company rule, and which expanded massively with the transfer of government to the Crown in 1858. By the mid-nineteenth century, it is clear that many prominent Indians were also beginning to see hospitals and dispensaries as a way of enhancing their position within their communities. Detailed work has only just begun on the establishment and running of philanthropic hospitals like the Jamsetji Jeejeebhoy Hospital in Bombay, but it is already clear that the number of such institutions and the growing popularity of hospitals for particular religious and caste groups should lead us to question some of the more sweeping, pessimistic assertions formerly made about Indian cultural resistance to Western medicine. Like any other people, Indians responded to the opportunities provided by hospitals in a balanced and rational manner, weighing up their merits and defects. Although suspicion of hospitals often increased at times of excitement, such as during epidemics, the overall trend was towards a growth in hospital use, though less among women than men. At first, Indians tended to be selective about which services they used. There was a marked preference for some surgical techniques, like cataract removal, and for certain therapies—such as quinine treatment for malaria—which had widely acknowledged benefits. However, in time, demand for all kinds of services spread within the context of an increasingly diverse and pluralistic medical marketplace. By the twentieth century, demand for hospital care was outstripping supply. State funding was never adequate to finance an effective hospital system, even in large urban areas such as Delhi, while Indian and European philanthropic efforts were unable to fill the gap.68 From 1910, the Government of India admitted that it would be unable to provide medical care for the majority of the Indian people, particularly in rural areas, and pinned its hopes on training more Indians in Western medicine. This meant ceding more power to Indian doctors in those hospitals that had been established, and from the 1920s, Indian practitioners lobbied successfully to become consultants.69 The rise of Indian-influenced hospital medicine is a story that has yet to be told; we also have very few accounts of medical practice and health care in rural areas, the only real exception being studies of missionary medicine. Missionaries employed medical care as a means of winning the trust of Indians in the hope that they would eventually convert to Christianity. Mission clinics were seldom successful in achieving their ultimate goal of conversion but in many remote areas, such as the tribal regions of India, and in locations such as the North West Frontier, they were often the only Western medical institutions and performed an important role, especially in cataract surgery and dispensing drugs.70 Private or semi-private initiatives to provide medical care for women, through missionary clinics and such bodies as the semiofficial Dufferin Fund, established by the wife of the viceroy in 1888, also had some localized success among Christian and low-caste women. However, they found it hard to persuade high-caste Hindus and Muslims to allow their women to enter Western establishments, even if staffed entirely by female doctors, midwives, and nurses.71

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Conclusion Missionary medicine, state medicine, and Indian medical traditions have all attracted considerable interest among historians of South Asia. It has been impossible to do justice to the numerous works on these subjects in a single chapter but this essay may provide a guide to readers approaching the subject of medicine in South Asia for the first time. It has mapped the contours of existing scholarship and identified some of the main themes and issues that have animated it. It has also pointed to important lacunae that remain to be filled. Would-be students of South Asian medicine and health care will find much in the primary sources that eludes them here and, if nothing else, the silences in this chapter may serve to indicate the vast opportunities that await any scholar willing to take up the challenge.

Notes 1. Francis Zimmerman, The Jungle and the Aroma of Meats: An Ecological Theme in Hindu Medicine (Berkeley: University of California Press, 1987). 2. Being oral cultures, most of these are lost to the historian, except through occasional references in some European texts. Some impression of these may be obtained from Sudhir Kakar, Shamans, Mystics and Doctors: A Psychological Inquiry into India and its Healing Traditions (New Delhi: Oxford University Press, 1982). 3. M. N. Pearson, ‘First Contacts between Indian and European Medical Systems: Goa in the Sixteenth Century’, in D. Arnold (ed.), Warm Climates and Western Medicine (Amsterdam: Rodopi, 1996), 20–41; M. N. Pearson, ‘The Thin End of the Wedge: Medical Relativities as a Paradigm of Early Modern Indian-European Relations’, Modern Asian Studies, 29 (1995), 141–70. 4. Pratik Chakrabarti, ‘ “Neither of meate nor drinke, but what the Doctor alloweth”: Medicine amidst War and Commerce in Eighteenth-Century Madras’, Bulletin of the History of Medicine, 80 (2006), 1–38; Pratik Chakrabarti, ‘Medical Marketplaces beyond the West: Bazaar Medicine, Trade and the English Establishment in Eighteenth-Century India’, in P. Wallis and M. Jenner (eds), Medicine and the Market in Early Modern England (London: Palgrave, 2007), 196–215. 5. C. S. Mohanavelu, German Tamilology: German Contributions to Tamil Language, Literature and Culture during the Period 1706–1945 (Madras: South India Saiva Siddhanta Works Publishing Society, 1993). 6. Dominick Wujastyk, ‘Change and Continuity in Early Modern Indian Medical Thought’, Journal of Indian Philosophy, 33 (2005), 95–118. 7. Mark Harrison, ‘Medicine and Orientalism: Perspectives on Europe’s Encounter with Indian Medical Systems’, in B. Pati and M. Harrison (eds), Health, Medicine and Empire: Perspectives on Colonial India (Hyderabad: Orient Longman, 2001), 37–87. 8. Poonam Bala, Imperialism and Medicine in Bengal (New Delhi: Sage, 1991); Anil Kumar, Medicine and the Raj: British Medical Policy in India 1835–1911 (New Delhi: Sage, 1998), 17–22.

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9. Kumar, Medicine and the Raj, 22. 10. B. D. Metcalfe, ‘Nationalist Muslims in British India: The Case of Hakim Ajmal Khan’, Modern Asian Studies, 19 (1985), 1–28; K. N. Panikkar, Culture, Ideology, Hegemony: Intellectuals and Social Consciousness in Colonial India (New Delhi: Tulika, 1995), 145–75; Neshat Quaiser, ‘Politics, Culture and Colonialism: Unani’s Debate with Doctory’, in Pati and Harrison (eds), Health, Medicine and Empire, 317–55. 11. Seema Alavi, Islam and Healing: Loss and Recovery of an Indo-Muslim Medical Tradition (Basingstoke: Palgrave, 2008). 12. J. C. Hume, ‘Rival Traditions: Western Medicine and Yunani-Tibb in the Punjab, 1849– 1899’, Bulletin of the History of Medicine, 51 (1977), 214–31. 13. Guy Attewell, Refiguring Unani Tibb: Plural Healing in Late Colonial India (Hyderabad: Orient Longman, 2007); Kavita Sivaramakrishnan, Old Potions, New Bottles: Recasting Indigenous Medicine in Colonial Punjab 1850–1945 (Hyderabad: Orient Longman, 2006). 14. Jean M. Langford, Fluent Bodies: Ayurvedic Remedies for Postcolonial Imbalance (Durham, NC: Duke University Press, 2002). 15. Projit Bihari Mukharji, ‘Medicine and Modernity in Colonial Bengal, c.1775–1930’, PhD thesis, University of London, 2006; Poonam Bala, ‘ “Defying” Medical Autonomy: Indigenous Elites and Medicine in Colonial India’, in P. Bala (ed.), Biomedicine as a Contested Site (Lanham: Lexington Books, 2009), 29–44. 16. Madhuri Sharma, ‘Western Medicine and Indian Responses: A Case Study of Banaras Region, c.1890–1947’, PhD thesis, Jawaharlal Nehru University, 2007. 17. Ira Klein, ‘Urban Development and Death: Bombay City, 1870–1914’, Modern Asian Studies, 20 (1986), 725–54. 18. Ian Catanach, ‘Plague and the Indian Village, 1896–1914’, in P. Robb (ed.), Rural India: Land, Power and Society under British Rule (London: Curzon Press, 1983), 216–43; idem, ‘Poona Politicians and the Plague’, South Asia, 7 (1984), 1–18; idem, ‘Plague and the Tensions of Empire: India, 1896–1918’, in D. Arnold (ed.), Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), 149–71; Ira Klein, ‘Plague, Policy and Popular Unrest in British India’, Modern Asian Studies, 22 (1988), 723–55. 19. Ranajit Guha, ‘On Some Aspects of the Historiography of Colonial India’, in R. Guha (ed.), Subaltern Studies I: Writings on South Asian History and Society (Delhi: Oxford University Press, 1982), 1–8. 20. David Arnold, ‘Cholera and Colonialism in British India’, Past and Present, 113 (1986), 118–51. 21. David Arnold, ‘Smallpox and Colonial Medicine in Nineteenth-Century India’, in idem (ed.), Imperial Medicine, 45–65; idem, ‘Touching the Body: Perspectives on the India Plague, 1896–1900’, in R. Guha (ed.), Subaltern Studies V: Writings on South Asian History and Society (Delhi: Oxford University Press, 1987), 55–90; idem Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Berkeley: University of California Press, 1993). 22. Rajnarayan Chandavarkar, ‘Plague Panic and Epidemic Politics in India, 1896–1914’, in T. Ranger and P. Slack (eds), Epidemics and Ideas: Essays on the Historical Perception of Pestilence (Cambridge: Cambridge University Press, 1994), 203–40. 23. Valeska Huber, ‘The Unification of the Globe by Disease? The International Sanitary Conferences on Cholera, 1851–1894’, The Historical Journal, 49 (2006), 453–76.

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24. Mark Harrison, ‘Quarantine, Pilgrimage, and Colonial Trade: India 1866–1900’, Indian Economic and Social History Review, 29 (1992), 117–44; Manjiri Kamat, ‘ “The Palkhi as Plague Carrier”: The Pandharpur Fair and the Sanitary Fixation of the Colonial State; British India, 1908–1916’, in B. Pati and M. Harrison (eds), Health, Medicine and Empire: Perspectives on Colonial India (Hyderabad: Orient Longman, 2001), 299–316; Biswamoy Pati, ‘ “Ordering” “Disorder” in a Holy City: Colonial Health Interventions in Puri during the Nineteenth Century’, in Pati and Harrison (eds), Health, Medicine and Empire, 270–98; Amna Khalid, ‘ “Subordinate” Negotiations: Indigenous Staff, the Colonial State and Public’, and Saurabh Mishra, ‘Beyond the Bounds of Time? The Haj Pilgrimage from the Indian Subcontinent, 1865–1920’, in B. Pati and M. Harrison (eds), The Social History of Health and Medicine in Colonial India (London: Routledge, 2008), 31–44, 45–73. 25. Amna Khalid, ‘The Colonial Behemoth: The Sanitary Regulation of Pilgrimage Sites in Northern India, c.1867–1915’, DPhil thesis, University of Oxford, 2008; Saurabh Mishra, ‘Pilgrimage, Politics and Pestilence: The Haj from the Indian Subcontinent, 1860–1920’, DPhil thesis, University of Oxford, 2008. 26. Harrison, ‘Quarantine, Pilgrimage and Colonial Trade’. 27. Sheldon Watts, ‘From Rapid Change to Stasis: Official Responses to Cholera in BritishRuled India and Egypt: 1860 to c.1921’, Journal of World History, 12 (2001), 321–74. 28. Sanchari Dutta, ‘Plague, Quarantine and Empire: British-Indian Sanitary Strategies in Central Asia, 1897–1907’, in Pati and Harrison (eds), The Social History of Health and Medicine, 93–112. 29. Ronald Ross, Memoirs (London: Murray, 1923), 17. 30. R. Palme Dutt, India Today (London: Gollancz, 1940), 79. 31. J. B. Harrison, ‘Allahabad: A Sanitary History’, in K. Ballhatchet and J. B. Harrison (eds), The City in South Asia (London: Curzon Press, 1980), 167–96. 32. H. R. Tinker, The Foundations of Local Self-Government in India, Pakistan and Burma (London: Pall Mall Press, 1954), 73. 33. Radhika Ramasubban, Public Health and Medical Research in India: Their Origins and Development under the Impact of British Colonial Policy (Stockholm: SAREC, 1982); Radhika Ramasubban, ‘Imperial Health in British India, 1857–1900’, in R. MacLeod and M. Lewis (eds), Disease, Medicine, and Empire: Perspectives on Western India and the Experience of European Expansion (London: Routledge, 1988), 38–60. 34. Kumar, Medicine and the Raj; Kabita Ray, History of Public Health: Colonial Bengal 1921– 1947 (Calcutta: K. P. Bagchi and Sons, 1998); J. C. Hume, ‘Colonialism and Sanitary Medicine: The Development of Preventive Health Policy in the Punjab, 1860–1900’, Modern Asian Studies, 20 (1986), 703–24. 35. David Arnold, ‘Medical Priorities and Practice in Nineteenth-Century British India’, South Asia Research, 5 (1985), 167–83. 36. Subho Basu, ‘Emergence of the Mill Towns in Bengal 1880–1920: Migration Pattern and Survival Strategies of Industrial Workers’, Calcutta Historical Review, 18 (1995), 97–134. 37. Roger Jeffery, The Politics of Health in India (Berkeley: University of California Press, 1988), 92. 38. Mark Harrison, Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914 (Cambridge: Cambridge University Press, 1994), 176–7. 39. Sandip Hazareesingh, The Colonial City and the Challenge of Modernity: Urban Hegemonies and Civic Contestations in Bombay (1900–1925) (Hyderabad: Orient Longman, 2007); Mridula Ramanna, Western Medicine and Public Health in Colonial

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40. 41. 42. 43. 44.

45.

46. 47.

48. 49. 50. 51. 52.

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Bombay 1845–1895 (Hyderabad: Orient Longman, 2002); Mridula Ramanna,‘Randchodlal Chotalal: Pioneer of Public Health in Ahmedabad’, Radical Journal of Health, 11 (1996), 99–111; V. R. Muraleedharan and D. Veeraraghavan, ‘Disease, Death and Local Administration: Madras City in early 1900s’, Radical Journal of Health, 1 (1995), 9–24. Sanjoy Bhattacharya, Mark Harrison, and Michael Worboys, Fractured States: Smallpox, Public Health and Vaccination Policy 1800–1947 (Hyderabad: Orient Longman, 2005). Sanjoy Bhattacharya, Expunging Variola: The Control and Eradication of Smallpox in India 1947–1977 (Hyderabad: Orient Longman, 2006). W. F. Bynum, ‘An Experiment that Failed: Malaria Control at Mian Mir’, Parassitologia, 36 (1994), 107–20. Sheldon Watts, ‘British Development Policies and Malaria in India 1897–c.1929’, Past and Present, 165 (1999), 141–81. V. R. Muraleedharan, ‘Malady in Madras: The Colonial Government’s Response to Malaria in the Early Twentieth Century’, in D. Kumar (ed.), Science and Empire: Essays in Indian Context (1700–1947) (New Delhi: Oxford University Press, 1991), 101–14; V. R. Muraleedharan, ‘Rural Health Care in Madras Presidency: 1919–39’, Indian Economic and Social History Review, 24 (1987), 324–34. M. B. McAlpin, ‘Famines, Epidemics and Population Growth: The Case of India’, in R. I. Rotberg and T. K. Rabb (eds), Hunger and History: The Impact of Changing Food Production and Consumption Patterns on Society (Cambridge: Cambridge University Press, 1985), 153–68; Simon Commander, ‘The Mechanics of Demographic and Economic Growth in Uttar Pradesh, 1800–1900’, in T. Dyson (ed.), India’s Historical Demography: Studies in Famine, Disease and Society (London: Curzon Press, 1989), 49–72; S. Zurbrigg, ‘Re-thinking the Human Factor in Malaria Mortality: The Case of Punjab, 1868–1940’, Parassitalogia, 36 (1994), 121–35; Elizabeth Whitcombe, ‘Famine Mortality’, Economic and Political Weekly, 28 (1993), 1169–79; Elizabeth Whitcombe, ‘The Costs of Irrigation: Waterlogging, Salinity and Malaria’, in D. Arnold and R. Guha (eds), Essays on the Environmental History of South Asia (New Delhi: Oxford University Press, 1995), 257–59; Kohei Wakimura, ‘Famines, Epidemics and Mortality in Northern India’, in P. Robb, K. Sugihara, and H. Yanagisawa (eds), Local Agrarian Societies in Colonial India: Japanese Perspectives (London: Curzon Press, 1996), 280–310. Sunil S. Amrith, Decolonizing International Health: India and Southeast Asia, 1930–65 (London: Palgrave, 2006). Ira Klein, ‘Death in India, 1871–1921’, Journal of Asian Studies, 22 (1973), 639–59; T. Dyson (ed.), India’s Historical Demography: Studies in Famine, Disease and Society (London: Curzon Press, 1989). Judith L. Richell, Disease and Demography in Colonial Burma (Singapore: NUS Press, 2006). Atsuko Naono, State of Vaccination: The Fight against Smallpox in Colonial Burma (Hyderabad: Orient Blackswan, 2009). Sumit Guha, Health and Population in South Asia from Earliest Times to the Present (London: Hurst, 2001), 68–94. Mike David, Late Victorian Holocausts: El Niño Famines and the Making of the Third World (London: Verso, 2001). Sheila Zurbrigg, ‘Re-thinking Public Health: Food, Hunger, and Mortality Decline in South Asian History’, in I. Qadeer, K. Sen, and K. R. Nayar (eds), Public Health and the Poverty of Reforms: The South Asian Predicament (Delhi: Sage, 2001), 174–97.

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53. Mark Harrison and Michael Worboys, ‘A Disease of Civilisation: Tuberculosis in Britain, Africa and India, 1900–39’, in L. Marks and M. Worboys (eds), Migrants, Minorities and Health: Historical and Contemporary Studies (London: Routledge, 1997), 93–124. 54. David Arnold, ‘Diabetes in the Tropics: Race, Place and Class in India, 1880–1965’, Social History of Medicine, 22 (2009), 245–62. 55. R. Doll, P. Page, J. A. Waterhouse and D. M. Parkin, Cancer in Five Continents (Geneva: International Union Against Cancer, 1966). 56. Arnold, Colonizing the Body. 57. Mark Harrison, Climates and Constitutions: Health, Race, Environment and British Imperialism in India, 1600–1850 (Delhi: Oxford University Press, 1999). 58. Sanjiv Kakar, ‘Leprosy in Colonial India, 1860–1940: Colonial Politics and Missionary Medicine’, Medical History, 40 (1996), 215–30; Biswamoy Pati and Chandi P. Nanda, ‘The Leprosy Patient and Society: Colonial Orissa, 1870s–1940s’, in Pati and Harrison (eds), The Social History of Health and Medicine, 113–28. 59. Waltraud Ernst, Mad Tales from the Raj: The European Insane in British India, 1800–1858 (London: Routledge, 1991); eadem, ‘Colonial Policies, Racial Politics and the Development of Psychiatric Institutions in Early Nineteenth-Century British India’, in W. Ernst and B. Harris (eds), Race, Science and Medicine, 1700–1960 (London: Routledge, 1999), 80–100. 60. Jane Buckingham, Leprosy in Colonial South India: Medicine and Conflict (Basingstoke: Palgrave, 2002); Sanjiv Kakar, ‘Medical Developments and Patient Unrest in the Leprosy Asylum’, in Pati and Harrison (eds), Health, Medicine and Empire, 188–216. 61. James Mills, Madness, Cannabis and Colonialism: The ‘Native-Only’ Lunatic Asylums of British India, 1857–1900 (London: Macmillan, 2000). 62. Sanchari Dutta, ‘Disease, Medicine and Hygiene in the Prisons of British India: Bengal, 1860–1910’, DPhil thesis, University of Oxford, 2007. 63. Philippa Levine, Prostitution, Race and Politics: Policing Venereal Disease in the British Empire (London: Routledge, 2003); Kenneth Ballhatchet, Race, Sex and Class under the British Raj: Imperial Attitudes and Policies and their Critics, 1793–1905 (London: Weidenfeld and Nicholson, 1980); Douglas M. Peers, ‘Soldiers, Surgeons and the Campaigns to Combat Sexually Transmitted Diseases in Colonial India, 1805–1860’, Medical History, 42 (1998), 823–54. 64. Ronald Hyam, Empire and Sexuality: The British Experience (Manchester: Manchester University Press, 1991). 65. Erica Wald, ‘Vice, Medicine, the Military and the Making of Colonial India, 1780–1880’, PhD thesis, University of Cambridge, 2009; Levine, Prostitution, Chapters 3–4; Harrison, Public Health, 74–6. 66. Sean F. Lang, ‘Maternal Mortality and the State in British India, c.1840–c.1920’, PhD thesis, Anglia Ruskin University, 2007. 67. Nils Brimnes, ‘Variolation, Vaccination and Popular Resistance in Early Colonial South India’, Medical History, 48 (2004), 199–228; Bhattacharya, Harrison, and Worboys, Fractured States, Chapter 1; Arnold, ‘Smallpox and Colonial Medicine’. 68. Samiksha Sehrawat, ‘Medical Care for a New Capital: Hospital and Government Policy in Colonial Delhi and Haryana, c.1900–1920’, DPhil thesis, University of Oxford, 2006. 69. Mark Harrison, ‘Introduction’, in M. Harrison, M. Jones, and H. Sweet (eds), From Western Medicine to Global Medicine: The Hospital beyond the West (Hyderabad: Orient Blackswan, 2009).

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70. David Hardiman, Missionaries and Their Medicine: A Christian Modernity for Tribal India (Manchester: Manchester University Press, 2008). 71. Maneesha Lal, ‘The Politics of Gender and Medicine in Colonial India: The Countess of Dufferin’s Fund, 1885–1888’, Bulletin of the History of Medicine, 68 (1994), 29–66.

Select Bibliography Arnold, David, Colonizing the Body: State Medicine and Epidemic Disease in NineteenthCentury India (Berkeley: University of California Press, 1993). Attewell, Guy, Refiguring Unani Tibb: Plural Healing in Late Colonial India (New Delhi: Orient Longman, 2007). Bhattacharya, Sanjoy, Mark Harrison, and Michael Worboys, Fractured States: Smallpox, Public Health and Vaccination Policy in British India, 1800–1947 (Hyderabad: Orient Longman, 2005). Dyson, T. (ed.), India’s Historical Demography: Studies in Famine, Disease and Society (London: Curzon Press, 1989). Harrison, Mark, Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914 (Cambridge: Cambridge University Press, 1994). Hodges, Sarah (ed.), Reproductive Health in India: History, Politics and Controversies (New Delhi: Orient Longman, 2006). Mills, James, Madness, Cannabis and Colonialism; The ‘Native Only’ Lunatic Asylums of British India, 1857–1900 (London: MacMillan, 2000). Pati, Biswamoy, and Mark Harrison (eds), Health, Medicine and Empire: Perspectives on Colonial India (Hyderabad: Orient Longman, 2001). ——— , and ——— (eds), The Social History of Health and Medicine in Colonial India (London: Routledge, 2009). Sivaramakrishnan, Kavita, Old Potions, New Bottles: Recasting Indigenous Medicine in Colonial Punjab, 1850–1945 (New Delhi: Orient Longman, 2006).

chapter 17

h istory of m edici n e i n austr a l i a a n d n ew ze a l a n d l inda bryder

The historiography of medicine in Australia and New Zealand has followed a similar trajectory to the history of medicine elsewhere, moving from heroic and progressive medical history to analytical and discursive ways of viewing the past that aim to contribute to a deeper understanding of the social, political, and cultural facets of earlier societies. The study of the history of medicine in Australia and New Zealand can offer specific contributions to the history of medicine, however, through an examination of the transfer of Western medical knowledge to new societies, and the interaction between Western science and health professionals and non-Western peoples over the past 200 years. Much of that history to date has focused on colonization in Africa and Asia. Australia and New Zealand differ from these other colonial encounters, in that they quickly became ‘white settler societies’ in which the newcomers numerically dominated indigenous people. As Australian historian Alison Bashford noted, Australian history (and she could have added New Zealand) unsettled the usual classifications in colonial historiography, for example with no neat categories of ‘colonial’ and ‘postcolonial’: colonization and nationalism took on different meanings in these predominantly white societies.1 Nor can one generalize across Australia and New Zealand, as David Arnold noted in his overview of ‘Medicine and Colonialism’.2 Through local studies, scholars in these countries have made significant contributions to the history of medicine that are of relevance well beyond their specific societies. This chapter considers trends in the writing of medical history in Australia and New Zealand since the 1980s. It traces the growing maturity of the discipline in this geographical region, as evidenced through the institution of a professional organization with its own journal. It pinpoints a particular contribution to the wider discipline, the history of the health of indigenous peoples and their interaction with the state as well as the current political resonances of such historiography. It also shows how the history of

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health and medicine contributes to a broader understanding of those societies and their sense of nationalism or identity. Finally it addresses transnationalism in health histories and the ways in which medicine in these societies reflected or deviated from developments in the international medical community. The chapter demonstrates how international histories of medicine, as well as local social and political histories, have been enriched by this expanding historiography.

The new social history of public health and medicine In 1994, I published an overview of the history of public health in Australia and New Zealand, in an international collection edited by Dorothy Porter. The article focused on health policies in Australia and New Zealand since the establishment of these colonies in the early to mid-nineteenth century. Settlers came primarily from Britain, bringing with them their cultural baggage, including ideas about science, medicine, and the appropriate role of the state. Some of these ideas were an affirmation of trends in the ‘Mother’ country while others were a rejection of what they had left behind. The article showed how public health policies were not just transposed to the colonies but were adapted and transformed in the new environment according to dominant social and political values and changes over time. It discussed the prevailing nineteenth-century view among the new settlers that these colonies were a ‘working-man’s paradise’ and how that led to a denial of health problems and to the belief that any extant problems were the responsibility of (and could be attributed to the failings of) the individual. By the early twentieth century, in common with other Westernized countries, new ideas about social and state responsibility emerged in the form of the modern welfare state; New Zealand led the way and became proud of its international reputation as a ‘social laboratory’ in respect to social reforms. These included the setting up of public health structures and preventive health services—in the form of institutions (for childbirth, tuberculosis, and mental health, for example), health education, and sanitary inspection. Further influenced by global factors such as the First World War, the 1918 influenza epidemic, and the 1930s economic depression, by the mid-twentieth century an extensive public health and social welfare infrastructure was in place in Australia and New Zealand though with local variants (for example, New Zealand’s universalist versus Australia’s insurance-based health policies). An important part of the history of health policy in Australia and New Zealand was how colonization and consequent dispossession impacted on the health of indigenous peoples and the ways in which the respective governments responded—or failed to respond—to their poor health following colonization. Official responses were influenced by broader ideas about race and by settler interests.3 This overview was informed by the historiographical developments of the 1980s, when historians of health, medicine, and welfare had moved away from triumphalist

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and progressive approaches to their subject-matter to a more sociological or social constructivist approach. The new history was particularly concerned with understanding issues of class, gender, and race, and the ways in which dominant (mainly white male middle-class) sectors in society sought and maintained power over minority groups. Issues such as eugenics and ‘national efficiency’, which influenced health policies in other Western nations, were also evident here, but with an added intensity in light of the large neighbouring Asian populations that European (mainly British) settlers feared might swamp their new colonies. In the 1990s, histories of health and medicine in Australia and New Zealand expanded exponentially to provide a rich historiography—as evidenced by the founding of a new journal, Health and History, the first issue of which appeared in 1998. The setting up of a specialist journal is generally seen as the mark of maturity of a discipline; this had happened ten years earlier with the establishment of the Social History of Medicine in Britain. Health and History was published by the Australian Society of the History of Medicine (ASHM, renamed the Australian and New Zealand Society of the History of Medicine in 2005). Warwick Anderson, one of the first editors of the new journal, reflected ten years later that there had been at the time ‘a sense of maturity that seemed to demand some flagship publication’. He wrote that the new journal ‘expansively encompassed the diversity of historical interests found in the ASHM’, further explaining, however, that as editor he had tried ‘to negotiate the perennial tensions between medically trained historians and those with higher degrees in history who express interest in medical issues’.4 The ASHM itself had been formed in 1984 and held its first national conference in 1989, at which time it had almost 300 members. Roy MacLeod, Professor of History at Sydney and an historian of science, dismissively said of the Society almost twenty years later that of the Society’s 400 members only 10 were ‘professionals’ (by which he presumably meant academic historians of medicine).5 This statistic was not, however, reflected at the Society’s conferences. Even at the Society’s first national conference in 1989 those presenters whose papers appeared in the conference proceedings and who had a medical background (17) were slightly outnumbered by those with a history or social science background (19).6 The balance altered further over the years; a survey of the 2005 ASMH conference reveals that 61 presenters came with a history or social science background and 20 from a medical background. Of course, the category into which the ‘historian’ is placed does not necessarily affect the rigour of that history; either could produce ‘good history’. In 2005 the new editor of Health and History, Hans Pols, commented that the quality of research in the history of medicine he encountered in Australia following his move from the United States to the Unit for History and Philosophy of Science, University of Sydney, in 2002 had far exceeded his expectations, and that the conferences of the Society ‘proved to be an inspiring meeting place of health care professionals and historians engaged in an enduring dialogue’.7 Despite attempts by the Society and its journal to adopt a broad church approach, I am not suggesting that there was no tension between historians coming from different backgrounds or approaches. One of the offshoots of changing trends in medical historywriting since the 1980s had been a growing tension between medically trained histor-

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ians and those coming from university history departments. Informed by medical sociology and social constructivist theories of history, the new social historians of medicine were sometimes perceived by medically trained historians to be engaged in ‘doctor bashing’, and some authors did indeed conceive of the medical profession as a monolithic block of middle-class white males intent on controlling the rest of the population. By the 1990s a tempering factor in the tension was the recognition by many social historians that the social constructivist model of history-writing was too formulaic and simplistic and overlooked the complexities and subtleties of the interactions between medicine and society. A new hospital history that considered both medical developments and patients’ perspectives was Janet McCalman’s history of the Royal Melbourne Women’s Hospital, which she entitled Sex and Suffering in order to stress the patient focus.8 In 2004, Randolph Albury, formerly professor of history and philosophy of science at the University of New South Wales, wrote positively of his collaboration with orthopaedic surgeon George M. Weisz of Sydney, and argued that ‘collaboration with health practitioners can be highly fruitful both in generating research questions and in assessing the salience of evidence relating to these questions’. He described it as a form of crosscultural collaboration.9 Yet such collaboration was not always possible, with differing world views and approaches. The triumphalism of some modern accounts of the history of Western medicine was still subject to criticism; for example, Australian medical historian Suzanne Parry remained wary in 2003 of the ‘persistent idea’ in such accounts that ‘Western science alone had, and continues to have, the solution to the improved health of people living in the tropics’.10

Indigenous health on the agenda While medicine in the colonial context was conceptualized in the 1980s as a ‘tool of Empire’,11 an historian of the African continent, Megan Vaughan, disputed this interpretation, arguing that at least in Africa European doctors were simply too thin on the ground and their instruments too blunt to be viewed either as liberators from disease (as the triumphalist view of medicine would have it) or as agents of oppression (as the social constructivists argued). Moreover, indigenous healing systems survived the onslaught of Western medicine and co-opted some of its features; indigenous people were not merely passive victims in the imperial onslaught.12 This more nuanced and empirically based approach to the interaction between Western medicine and indigenous people was picked up in New Zealand and highlighted in a special issue of Health and History on Māori health in 2001. This incorporated aspects of health history such as Māori childbirth experiences, infant welfare, and the political and cultural relationship between biomedicine and colonialism. Commenting on the special issue, Ian Anderson, Director of a University of Melbourne centre for the study of Koori (Aboriginal) health and society, wrote that this collection of essays ‘taps the methodological and intellectual edge of a growing body of historical analysis broadly focused on the historical relationship

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between Indigenous peoples, the State and biomedical institutions, and the specific contexts of settler colonial states such as New Zealand, Australia, Canada and the United States’. He explained that he had ‘long noted the absence of an established critical inquiry on these issues’ within his own Australian context and was therefore ‘excited by the growing scholarship of these issues within the context of New Zealand colonial relations’.13 This special issue drew upon historical research conducted in the 1990s, much done by graduate students in unpublished dissertations and theses, and upon two important books that had appeared in 1999, by Derek Dow and Raeburn Lange.14 With an eye to the available ‘tools’ of Western medicine, in his history of the New Zealand government’s health policies towards Māori, Dow offered a more nuanced account than had hitherto been provided. On the one hand, he showed that Western medicine was not simply a ‘gift of civilization’ bestowed on the Māori people; he used the phrase ‘benevolent selfinterest’ to describe some health initiatives. On the other hand, he challenged some of the more strident political statements about the effects of colonization on Māori health and the neglect by the dominant white population.15 Dow discussed various policies the government enacted and financed, and which doctors supported and administered, in an attempt to improve Māori health. Lange focused more closely on the first two decades of the twentieth century and the involvement in Māori health of the first generation of Māori doctors. In both histories, Māori were shown to play an active part in health policy development; they were far from passive victims of colonization. Mason Durie, a psychiatrist and Māori leader who turned to history with a more explicit political agenda, had earlier stressed the Māori ability to survive and eventually flourish in the face of new challenges, through adaptation and agency.16 This historiography was further developed in the following years; for instance in 2006, Angela Wanhalla published an article on health and housing in Māori communities in the 1930s and 1940s. In this article she discussed housing as a form of Europeanization of Māori society, but also showed that the notion of the ‘home’ and its relationship with Māori health was constantly negotiated by government officials and Māori communities, and that Māori families only ‘selectively adopted western spatial usages of the home’.17 In 2007, Ian Anderson himself edited a special issue of Health and History on Aboriginal health history, together with his colleague Kim Humphery. In his editorial, Anderson commented on the ‘relatively patchy’ development of a historical focus on Aboriginal health, in contrast to Māori health. He explained how the Māori health issue had prompted him and Humphery to bring together a similar collection for the Australian context. The collected essays followed three themes: the Aboriginal experience of health and health services over time; the colonial and twentieth-century construction of medical knowledge in relation to Aboriginal health; and the recent history of Aboriginal health organizations. The language describing the treatment of Aborigines by the colonizers was much more damning than in the New Zealand studies: Anderson wrote how the articles provided evidence of the ‘personal and collective memory of health and welfare systems as a terrain of moral policing, neglect, incompetence and spiritual violation’.18 The authors in Anderson’s issue were influenced primarily by

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anthropological and ethnographic studies; unlike their New Zealand counterparts, they drew less on secondary historical works or maybe there were fewer to draw upon. Much of the focus was on recent history and memories, though with a sense of the legacy of the past. For instance, Bronwyn Frederick’s essay on Aboriginal women’s health focused primarily on the 1990s but included the comment that: The destruction that began in 1788 continues to impact on Aboriginal peoples’ lives, cultures, and health and wellbeing. Aboriginal peoples also know the impact that the history of colonisation has had on them and what it means in terms of health status. As is evident from Kay’s statement [her interviewee], Aboriginal women know what this health status means in terms of the lived reality.19

One historical account of Aboriginal health that did not appear in the footnotes of any of the 2007 special issue essays was Judith Raftery’s 2006 history of government policies and actions in relation to Aboriginal health in South Australia, perhaps showing how sometimes social anthropologists and historians continue to talk past each other.20 Nor was there mention (apart from in Warwick Anderson’s overview) of Gordon Briscoe’s 2003 study: himself an Aboriginal scholar, Briscoe fulfilled the political demand that indigenous peoples write their own histories. Comparing medical services for Aborigines in Queensland and Western Australia between 1900 and 1940, Briscoe showed how the priority in both places was to prevent the spread of Aboriginal diseases into white communities; in Queensland (as the most segregated of the states) this generally meant isolating and limiting the mobility of the indigenous people, and in Western Australia (where authorities strongly favoured assimilation) it led to efforts to ‘produce a dusky proletariat’.21 Like the authors of the 2007 Health and History issue, Raftery addressed the destructiveness of colonization, leading one reviewer to complain that she faced the danger of portraying Aborigines as ‘victims and losers’.22 This contrasts with Dow, Lange, and Durie’s portrayal of the New Zealand situation. Perhaps the difference was partly a reflection of the reality of different cultural groups and social and political circumstances. Reviewing Dow’s book, Janet McCalman wrote that for ‘all the shortcomings of Maori health care and status since colonization, the marvel to an Australian historian is that a book can be written at all about Maori health and government policy that begins in 1840.’23 As Warwick Anderson pointed out, the ‘diversity of Indigenous experience and the patchiness of historical analysis defy any simple transnational comparison of health developments.’24 Stephen Kunitz had attempted such a comparative study in 1994, reviewing the impact of European contact on indigenous peoples of the United States, Canada, Australia, and New Zealand. He argued that the major determinant of differences in contemporary health status was the different ways in which governments had dealt with indigenous peoples in the past. As Professor in a Department of Community and Preventive Medicine, Kunitz brought his scientific and epidemiological background to bear on his history-writing. He explained that for his comparative studies of the impact of colonization on respective colonial peoples, he aimed to assess the importance of certain variables by setting up controls. Thus:

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once disease ecology has been held roughly constant, one can see more clearly the ways in which colonial policy and political institutions have shaped the affairs of indigenous peoples. And once policy has been held constant, one can see more clearly how culture can make a difference. And once culture has been held constant, one can see how gender and status make a difference.25

A social or cultural historian might question such scientific precision, arguing that an epidemiological model could easily overlook local vagaries; and, indeed, for New Zealand, Kunitz relied primarily on the work of a demographer, Ian Pool, rather than the work of historians.26 Writing on any aspect of indigenous histories since the 1980s has had political resonance; historical consciousness has been closely allied to current political activism and government responses. Australian historian Suzanne Parry commented that indigenous history would remain on the political agenda ‘as long as Australian governments remained embroiled in issues of reconciliation, and the welfare of indigenous people is subject to international scrutiny’, and as long as the ‘legitimacy of actions taken in Australia’s colonial past is hotly contested’.27 An example of contemporary interest in historical writing was Warwick Anderson’s 2002 study of white Australia, which led to Adelaide University apologizing to Aboriginal peoples for the ‘barbarous’ experiments some of its scientists had performed in the 1930s.28 This was research into ‘half-caste’ Aboriginals in various parts of Adelaide, Victoria, Western Australia, and Queensland (with ‘half-castes’ defined as persons with some Australian ancestry who did not qualify as white, a cohort estimated at 23,000 in 1936), in which the researchers measured their physiology and anatomy, including blood groups and genealogies, offering lollies and cigarettes as bribes. As long as the health differentials between the dominant white population and indigenous peoples remain, the effects of colonization will continue to have political currency. In New Zealand, health forms a background to many claims under the Treaty of Waitangi Act 1974, which established a tribunal to make recommendations on compensation claims by Māori for loss of possessions and for infringements of the 1840 Treaty of Waitangi.29 Yet historians must be wary of broad generalizations about the health effects of colonization, neither seeing the colonizing state as monolithic and all-powerful nor viewing indigenous peoples as passive victims. More in-depth studies of interactions within health systems, in both Australia and New Zealand, are required for a balanced perspective. Under the ostensibly antiquarian title of ‘What Professor Cleland Did in His Holidays’, in 2002 David Thomas provided an incisive study of Australian Professor John Burton Cleland’s research into indigenous health in the first half of the twentieth century. He portrayed Cleland as a typical scientist of his day, collecting data about Aboriginal bodies and sickness in the same way as he observed and collected specimens of birds, plants, and animals. However, he also argued that, although Cleland himself portrayed the research encounter as Aboriginal people submitting to white power, there was evidence of Aboriginal choice and resistance.30

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White Australia and national identity One way in which the history of Aboriginal health has entered the Australian historiography is not through a direct assessment of policy relating to their welfare or their responses, but rather through perceptions of them as ‘other’. This has been part of the attempt to explain the construction of a white settler identity, citizenship, and nationalism. Upon federation of the Australian colonies in 1901, the new federal government passed the Immigration Restriction Act and the Pacific Island Labourers Act (outlawing ‘coloured labour’), which formed the basis of what became popularly known as the ‘White Australia’ policy. This impacted not only upon immigration (particularly from Asia) but also upon popular perceptions of, and policies towards, indigenous and white Australians. The policy was based on an ideal of protecting white Australia; as Alison Bashford wrote, it was ‘explicitly a nationalism of race’.31 Australian historians have begun to look at the ways in which public health, scientific discourses, and cultural representations of diseases buttressed the ideas of white Australian nationalism. This history-writing was influenced not so much by sociological understandings of disease and medicine that had emerged in the 1980s, but rather by cultural anthropology. Again, this was an avenue explored in the African context by Megan Vaughan, who sought to understand cultural representations of disease and the influence of medical ideas and practices on the shaping of colonial images of Africa.32 Suzanne Parry brought a similar approach to her studies of tropical medicine in northern Australia and the influence of the white Australia policy in that area. She argued that ‘an important component in the process of identity formation amongst colonizers was to position indigenous people and to thus “identify” them in particular ways’. She showed how the discourse of tropical medicine, validated by its scientific status, was used to legitimize the subjugation of indigenous people, and how the ‘medicalised body became an important signifier of difference between white settler and indigenous people in northern Australia’.33 Crucial to the development of a white settler society in the north was the defining of Aborigines as ‘other’, as diseased and therefore a direct threat to northern development and in need of control. Asian people, persistently viewed as diseased and contaminating, were to be excluded as far as possible from this white society. As historian David Walker wrote, the ‘diseased and turbulent East provided a convenient and culturally powerful threat for the Australian colonies as they sought the common ground of nationhood at the end of the nineteenth century’.34 Another perceived way of nation-building was to make the environment safe for white settlement; this was the primary goal of the new Institute for Tropical Medicine established in Townsville in 1910. The first director of the Institute from 1910 to 1920, protozoologist Anton Breinl, defined this goal: ‘The object of tropical medicine involves much more than the study of parasites and diseases occurring in the tropics; it comprises in its working sphere the welfare and life of the white man under new, and, to him, artificial conditions.’35

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Suzanne Parry’s work related specifically to leprosy, as she explained in Health and History: ‘The health of the people and confirmation of the successful transplanting of white bodies to an alien land were essential to the emerging Australian identity, and leprosy, a disease which stamped its claim on the body so visibly, posed a threat to the process of physical adaptation.’36 In his research on the Institute for Tropical Medicine, Andrew Parker also linked tropical medicine and the white Australia policy, showing how the maintenance of ‘normal health’ required the protection of society from diseases, and ‘more sinisterly’ from their transmission by certain diseased populations. He cited Sir Raphael Cilento, later Director-General of Health and Medical Services in Queensland from 1934 to 1946, who declared in 1928 that the major factors in tropical white settlement in the early twentieth century had been not only ‘the successful institution of adequate measures of preventive medicine’ and ‘the continual increase in locallyborn inhabitants’, but also ‘the exclusion of races with lower standards of life and higher rates of disease and reproduction’.37 Two important studies detailing the relationship between health, medicine, and the white Australia policy were Warwick Anderson’s The Cultivation of Whiteness and Alison Bashford’s Imperial Hygiene. Reviewing Bashford’s book, Anderson commented: Some might say that one cannot carve out a realistic history of medicine and public health in this country [Australia] without paying attention to the invading tendrils and suckers of race, hygiene and nation. Others will dismissively point to the influence of fashion in the contemporary academic allotment. But, whatever the cause, it is clear that Australians are leading other historians of medicine in exploring the links between public health policies and estimates of civic virtue. Imperial Hygiene, while it covers some familiar grounds, adds notably to this enterprise.38

It was a trend to which Anderson himself was a major contributor. In The Cultivation of Whiteness, he sought to show how biomedical science and public health ‘helped to set a nation’s racial agenda’, arguing that the ‘medical construction of white Australia provides another lens through which we may view two hundred years of European settlement’. His book was divided into three sections, dealing with the ‘Temperate South’, the ‘Northern Tropics’, and ‘Aboriginal Australia’. Anderson pointed out that science and medicine were ‘often left out of the conventional histories of Australia—or of any other country for that matter’. He aimed to explore ‘fears of white degeneration in the antipodes, whether from an exhausting depleting environment, from contact with other races, or from urban life’. In the final section, he discussed how doctors came to believe that it was beneficial to remove ‘half-caste’ children from their families so that they would grow up white and become ‘good’ white citizens, leading to the tragedy of the ‘stolen generations’. He showed how scientific experiments were conducted on Aboriginal people in the 1930s. After the Second World War, he explained, race as a scientific concept largely collapsed, but the research and policies derived from it left a lasting legacy; it took a 1967 referendum to start dismantling Australia’s highly racialized society by allowing indigenous people to be counted in the census for the first time, thus finally granting them the vote and citizenship.39

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Bashford’s book is complementary to Anderson’s. Hers was a ‘cultural history of borders, hygiene and race’ from the 1860s to the Second World War. Rather than focusing on scientific ideas per se, Bashford addressed the relationship between public health and liberal governance in Australia, under the unifying concept of ‘hygiene’. Her book covered such topics as vaccination, smallpox, tuberculosis, leprosy, quarantine, immigration, and venereal disease. She showed how vaccination and the accompanying certificate created an early form of identification for travel, effectively becoming a passport; thus public health was implicated in nation-building. She contrasted responses to tuberculosis (the ‘white plague’) and leprosy (the ‘imperial disease’). In her chapter on quarantine, she argued that national maritime quarantine was integral to the rise of Australian nationalism. Quarantine regulations assisted Australians to regard themselves as inhabitants of a nation-state with borders, a ‘pure’ island to be protected from invading diseases. In the chapter on immigration, she discussed the formulation of the white Australia policy at the turn of the century and the ways in which public health assisted in its maintenance. She noted that ‘whiteness was the national identity of this particular twentieth century imagined community’. ‘Whiteness’ and ‘purity’ were also implicated in the domestic social hygiene and eugenic movements of the interwar years, the subjects of the last chapter of her book. Here she discussed isolation and sterilization as forms of eugenic cordons sanitaires, boundaries protecting future generations from disease.40 Public health and national identity have not been explored in the New Zealand context as in Australia. However, much has already been written on racial stereotypes and medical attitudes to Māori in the nineteenth century, suggesting a typecasting of them as ‘other’.41 In her review of Derek Dow’s book on Māori health and government policy, McCalman suggested taking this historiography further. In her opinion, ‘this New Zealand story now needs another history that locates it in the wider debates over race fitness, germ theory and of the relationship between civilization and sanitation. New Zealand distinctiveness is too important to the global historiography of colonisation for it to be discussed only in the Antipodes.’42 Some historians of medicine have employed public health issues to define New Zealand in relation to Britain. Philippa Mein Smith’s article on the history of the nation’s milk production and consumption offers a brief foray into the history of New Zealand’s self-identity and its relationship with the imperial centre through the lens of public health.43 Pamela Wood’s cultural history of dirt similarly suggested a new way of looking at New Zealand’s colonial past, by addressing the part ‘dirt’ and public health played in the vision and realization of a New World settlement.44 While there is scope for more work in the cultural history of ideas in relation to health and medicine, an eye to the social context remains important. In his review of Bashford’s book, Warwick Anderson complained that, ‘as in the Foucauldian schema, there is little recognition of contestation of these discourses on hygiene, nor of public indifference to, or subversive appropriation of, the plans of the public health officer. (In other words, there could be as much on the actual crossing, or disregard, of the boundaries as on their construction.)’45 Many historians would agree with this assessment, and continue to value social, local, and empirical history, arguing for the importance of understanding the ways

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in which individuals responded to the cultural imperatives. Anderson noted in his review that it would also have been helpful to locate more precisely the agents of racial hygiene, in their social, institutional, and geographical settings. An example of the neglect of such detail in Bashford’s account relating to the major actors is the information provided on Cilento. Bashford’s index includes only eight references to Raphael Cilento: in the first we learn that he was ‘Chief Medical Officer and chief Protector of Aborigines’ (though no dates are given other than ‘after 1940’); the other references are to his views. One can refer to a dictionary of biography for more detail, and yet some assessment of him as an individual by Bashford herself would surely help to explain his views and actions.

Transfer of knowledge and trans-nationalism When Warwick Anderson regretted that Bashford’s ‘agents of hygiene’ were not placed in their wider setting, he suggested that there was much more to say about broader connections: ‘we have yet to explore properly the many connections between Australian events and adjacent colonial developments. Practices of hygiene, and the careers of the advocates of hygiene, travelled through South-east Asia, Australia and the Pacific, but historians have rarely followed. Cilento, for example, moved between colonial Malaya, tropical Australia and Papua and New Guinea.’ He indicated that along with Lenore Manderson and Donald Denoon, he had begun to track some of these intercolonial connections.46 This transfer of knowledge and expertise does not just apply to that geographical area, however, but must be set in an imperial and even international context. James Gillespie and later Annie Stuart addressed this wider interaction when they focused on the involvement of the American philanthropic organization the Rockefeller Foundation in the early-twentieth-century hookworm campaign in Australia and its territories, leading the latter to comment on the Rockefeller’s ‘global influence over modern public health and medical systems’.47 Medical historian Milton Lewis explained that he placed his Australian history of sexually transmitted diseases (STD) into an international context because ‘historically, Australia was a political dependent of Britain and a cultural dependent of Britain, Europe and the US’. He adopted this comparative approach not only to show the influence of the older countries upon medical policies in Australia but also the differences, for example compulsion in interwar STD control in Australia compared with reliance on voluntary attendance at public STD clinics in Britain.48 It could be added that New Zealand, unlike Australia, also opted for the voluntary approach.49 These narratives contribute to our understanding of cultural, social, economic, and political factors that underlay responses to such diseases. Placing the medical practices of one particular institution, New Zealand’s National Women’s Hospital, into an international context also facilitated fresh insights into events that led to a significant government inquiry in 1987.50

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Transnational links were often at an individual level. Most Australian and New Zealand doctors practising before the First World War had done their medical training in the United Kingdom, and many continued to undertake post-graduate training there after that time. Until 1962 in Australia and 1967 in New Zealand, the medical profession was organized locally as branches of the British Medical Association, providing them personal access to the British Medical Journal. Many of those holding influential posts in health administration had connections with Britain. Dr J. H. L. Cumpston, for instance, described by Lewis as ‘undoubtedly the most important figure in public health in Australia’ in the twentieth century, had gained the London Diploma in Public Health (DPH) in 1906, and worked briefly at the Lister Institute of Preventive Medicine in London.51 Dr J. S. C. Elkington, another leading figure in Australian public health, also held the London DPH. Both Dr J. A. Thompson, head of the Department of Public Health of New South Wales in its formative years from 1896 to 1914, and Dr W. C. Armstrong, Sydney’s medical officer from 1898 to 1913 and recognized as the founder of the infant welfare movement in Australia, held a DPH from Cambridge. The founder of the infant welfare movement in New Zealand, Dr Truby King, gained the new BSc in Public Health at Edinburgh University in 1887. Dr J. M. Mason, appointed the first Chief Health Officer under New Zealand’s Public Heath Act of 1900, had also been awarded a Cambridge DPH, as had Dr R. H. Makgill, who framed the 1920 Health Act in New Zealand. And so the list goes on; such connections persisted well into the twentieth century, showing New Zealand and Australia to be intimately connected with the metropolitan centre.52 Ideas and the people themselves travelled freely within the British Empire and beyond; increasingly North America and Scandinavia were included in overseas study trips. Imperial connections came under close scrutiny in Anne Crowther and Marguerite Dupree’s study of the fortunes of 1,288 doctors who graduated from the Scottish universities in Edinburgh and Glasgow in the 1870s. Crowther and Dupree traced the careers of these graduates and highlighted medical networks. Of those they traced, sixty-nine ended up in Australia and eighteen in New Zealand. They showed how these antipodean practitioners remained abreast of European ideas through intercolonial conferences, medical societies, books, and journals. Interestingly in the light of comparative history and race relations mentioned above, Crowther and Dupree also noted: ‘A major difference between the experience of the Australian and the New Zealand doctors was that the former rarely encountered, or mentioned, the indigenous people.’53 Transnationalism involves the study of connections but also the transfer of ideas and cultures across national borders. These ideas did not always simply travel in one direction—see for example, the influence of the New Zealand infant welfare reformer Sir Frederic Truby King in Britain.54 And differences as well as similarities become explanatory. For example, how mental health and asylum developments played out in the colonial context contributes to a broader understanding of the history of psychiatry. Australian historian of psychiatry Stephen Garton recently explained: The dispossession of indigenous Australians, the marked gender disparities of colonial society, the ethic of custodialism that has afflicted Australian practices of

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institutionalisation since colonisation, the difficulties of governing a widely dispersed population, the struggle of the professional classes to gain a legitimate foothold in Australian society—all had a bearing on the character of the lunatic asylum in Australia.55

Understanding this distinctiveness helps to elucidate the social and cultural construction of medical knowledge and medical institutions. Yet the patient focus of much recent asylum history also contributes to the histories of colonial societies and migration, for example Barbara Brookes’s work on the Seacliff Asylum, Dunedin, and Angela McCarthy’s recent work on the Irish diaspora and the Auckland Asylum.56 Another contribution to this genre is Catharine Coleborne’s work on the case books relating to Chinese patients in a colonial asylum in Victoria, Australia.57

Conclusion This overview is not intended as a comprehensive survey of the writing of the history of medicine in Australia and New Zealand, which has been influenced by and contributes to the broader medical historiography through its methodology and historical constructs. Rather I have chosen to highlight areas of distinctiveness, such as the interactions between medicine, race theory and race relations, and trans-nationalism. Just as Janet McCalman commented that Dow’s book deserved an audience wider than that found in Australasia, so too are there many other areas of modern history of medicine where antipodean scholars are at the forefront of trends in medical history-writing and methodologies. While the publication of a regionally based journal signalled the coming of age of the discipline in that part of the world, there is also the danger that having such a geographically based journal could lead to the ghettoization of scholarship from that region, with it not reaching the wide readership it deserves. This chapter has attempted to signpost some potentially fruitful avenues for future historical research. There is clearly room for more nuanced work relating to the interaction between indigenous populations and officialdom, viewing the former neither as simply beneficiaries of the state nor as victims. Historians have explored how government policies endorsed or bolstered national identities but not how these imperatives were interpreted or received at grass-roots levels. Finally, there is more work to be done in locating medical policies and developments in an international perspective. Medical historians have yet to investigate in depth the ways in which hospital, primary care, and public health systems were distinctive in this region and what this tells us about prevailing social attitudes and ideologies. Seemingly poised on the edge of the world, these antipodean nations have perceived themselves as part of the Western world and yet are not Western; they have perceived themselves as white and British even, and yet are multicultural. Studies of their distinctiveness as well as similarities with older countries will continue to contribute to the historiography of public health and medicine.

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Notes 1. Alison Bashford, Imperial Hygiene: A Critical History of Colonialism, Nationalism and Public Health (New York: Palgrave Macmillan, 2004), 3. 2. David Arnold, ‘Medicine and Colonialism’, in W. F. Bynum and Roy Porter (eds), Companion Encyclopaedia of the History of Medicine, vol. 2 (London/New York: Routledge, 1993), 1393–416. 3. Linda Bryder, ‘A New World? Two Hundred Years of Public Health in Australia and New Zealand’, in Dorothy Porter (ed.), The History of Public Health and the Modern State (Amsterdam: Rodopi, 1994), 313–34. For a similar more recent overview see Milton Lewis, ‘Public Health in Australia from the Nineteenth to the Twenty-first Century’, in Milton J. Lewis and Kerrie L. MacPherson (eds), Public Health in Asia and the Pacific: Historical and Comparative Perspectives (London/New York: Routledge, 2008), 222–49. 4. Warwick H. Anderson, ‘Ten Years and More of Health & History’, Health and History 10 (1) (2008), 1–4. 5. Roy MacLeod, ‘Colonial Doctors and National Myths: On Telling Lives in Australian Medical Biography’, in Mary P. Sutphen and Bridie Andrews (eds), Medicine and Colonial Identity (London: Routledge, 2003), 126. 6. Harold Attwood, Richard Gillespie, and Milton Lewis (eds), New Perspectives on the History of Medicine: First National Conference of the Australian Society of the History of Medicine 1989 (Melbourne: University of Melbourne and the Australian Society of the History of Medicine, 1990). 7. Hans Pols, ‘From the Editor’, Health and History 7 (1) (2005), 1. 8. Janet McCalman, Sex and Suffering: Women’s Health and a Women’s Hospital: The Royal Women’s Hospital, Melbourne, 1856–1996 (Carlton, Victoria: Melbourne University Press, 1998). 9. W. R. Albury, ‘Broadening the Vision of the History of Medicine’, Health and History 7 (1) (2005), 2–16. 10. Suzanne Parry, ‘Tropical Medicine and Colonial Identity in Northern Australia’, in Sutphen and Andrews (eds), Medicine and Colonial Identity, 104, citing F. E. G. Cox, Illustrated History of Tropical Medicine (London: Wellcome Trust, 1996), 154. 11. David Arnold (ed.), Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988); Roy MacLeod and Milton Lewis (eds), Disease, Medicine and Empire: Perspectives on Western Medicine and the Experience of European Expansion (London/New York: Routledge, 1988). 12. Megan Vaughan, ‘Healing and Curing: Issues in the Social History and Anthropology of Medicine in Africa’, Social History of Medicine 7 (2) (1994), 283–95. 13. Ian Anderson, ‘Editorial to Maori Health Special Issue, Guest Editors Linda Bryder and Derek A. Dow’, Health and History 3 (1–2) (2001), 1–2. 14. Derek A. Dow, Maori Health and Government Policy 1840–1940 (Wellington: Victoria University Press in association with the Historical Branch, Department of Internal Affairs, 1999); Raeburn Lange, May the People Live: A History of Maori Health Development 1900– 1920 (Auckland: Auckland University Press, 1999). The theses are listed in Linda Bryder and Derek A. Dow, ‘Maori Health History Past, Present and Future’, Health and History 3 (1) (2001), 3–12. 15. Linda Tuhiwai Smith, Decolonizing Methodologies: Research and Indigenous Peoples (New York: Zed Books; Dunedin: University of Otago Press, 1998).

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16. Mason Durie, Whaiora: Maori Health Development (Auckland: Oxford University Press, 1998). 17. Angela Wanhalla, ‘Housing Un/healthy Bodies: Native Housing Surveys and Maori Health in New Zealand 1930–45’, Health and History 8 (1) (2006), 100–20. 18. Ian Anderson and Kim Humphery, ‘Editorial: Aboriginal Health & History’, Health and History Special Issue: Aboriginal Health and History 9 (2) (2007), 3. 19. Bronwyn Fredericks, ‘Australian Aboriginal Women’s Health: Reflecting on the Past and Present’, Health and History Special Issue: Aboriginal Health and History 9 (2) (2007), 97. 20. Judith Raftery, Not Part of the Public: Non-Indigenous Policies and Practices and the Health of Indigenous South Australians 1836–1973 (Kent Town, South Australia: Wakefield Press, 2006). 21. Gordon Briscoe, Counting, Health and Identity: A History of Aboriginal Health and Demography in Western Australia and Queensland, 1900–1940 (Canberra, ACT: Aboriginal Studies Press, 2003). 22. Kyllie Cripps, Book Review of Raftery, Health and History 8 (2) (2006), 177. 23. Janet McCalman, Book Review of Dow, Medical History 46 (4) (2002), 600–1. 24. Warwick Anderson, ‘The Colonial Medicine of Settler States: Comparing Histories of Indigenous Health’, Health and History Special Issue: Aboriginal Health and History 9 (2) (2007), 150. 25. Stephen Kunitz, Disease and Social Diversity: The European Impact on the Health of NonEuropeans (New York/Oxford: Oxford University Press, 1994), 23, 177. 26. D. Ian Pool, Te Iwi Maori: A New Zealand Population, Past, Present and Projected (Auckland: Auckland University Press, 1991). 27. Parry, ‘Tropical Medicine and Colonial Identity in Northern Australia’, 103. 28. Warwick Anderson, The Cultivation of Whiteness: Science, Health and Racial Destiny in Australia (New York: BasicBooks, 2003). 29. Linda Bryder, ‘Health Citizenship and “Closing the Gaps”: Maori and Health Policy’, in Astri Andresen, Tore Gronlie, William Hubbard, Teemu Ryymin, and Svein Atle Skalevag (eds), Citizens, Courtrooms, Crossings: Conference Proceedings, Report 10–2008 (Bergen: Stein Rokkan Centre for Social Studies, December 2008), 55–66. 30. David Thomas, ‘What Professor Cleland Did in His Holidays: Collecting Expeditions to Central Australia as Indigenous Health Research, 1925–39’, Health and History 4 (2) (2002), 57–79. 31. Bashford, Imperial Hygiene, 3. 32. Vaughan, ‘Healing and Curing’. 33. Parry, ‘Tropical Medicine and Colonial Identity in Northern Australia’, 103–24. 34. David Walker, Anxious Nation: Australia and the Rise of Asia, 1850–1939 (Brisbane: University of Queensland Press, 1999); idem, ‘Review Essay: A Sunburnt Country: Reflections on Race, Whiteness and the Geopolitics of Settlement in Australia’, Health and History 4 (2) (2002), 118–24. 35. Bashford, Imperial Hygiene, 159. 36. Suzanne Parry, ‘ “Of Vital Importance to the Community”: The Control of Leprosy in the Northern Territory’, Health and History 5 (1) (2003), 1. On leprosy history, see also Anne O’Brien, ‘ “All Creatures of the Living God”: Religion and Leprosy in Turn of the Century Queensland’, History Australia 5 (2) (2008), 40. 37. Andrew Parker, ‘A Complete Protective Machinery: The AITM, 1911–28’, Health and History 1 (2 & 3) (1999), 190.

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38. Warwick Anderson, Book Review, Health and History 6 (2) (2004), 111. 39. In New Zealand, Māori were included in universal manhood suffrage introduced in 1889, and in universal suffrage from 1893. 40. Bashford, Imperial Hygiene. See also Alison Bashford and Claire Hooker (eds), Contagion: Historical and Cultural Studies (London: Routledge, 2001); Carolyn Strange and Alison Bashford (eds), Isolation: Places and Practices of Exclusion (New York: Routledge, 2003); Alison Bashford (ed.), Medicine at the Border: Disease, Globalization, and Security, 1850 to the Present (New York: Palgrave Macmillan, 2006). On quarantine and identity, see K. Maglen, ‘A World Apart: Geography, Australian Quarantine and the Mother Country’, Journal of the History of Medicine and Allied Sciences 60 (2) (2005), 196–217. 41. Malcolm Nicolson, ‘Medicine and Racial Politics: Changing Images of the New Zealand Maori in the Nineteenth Century’, in Arnold (ed.), Imperial Medicine and Indigenous Societies, 66–104; James Belich, Making Peoples: A History of the New Zealanders: From Polynesian Settlement to the End of the Nineteenth Century (Auckland: Penguin, 2007). 42. McCalman, Book Review, 600–1. 43. Philippa Mein Smith, ‘New Zealand Milk for “Building Britons”’, in Sutphen and Andrews (eds), Medicine and Colonial Identity, 79–102. 44. Pamela Wood, Dirt: Filth and Decay in a New World Arcadia (Auckland: Auckland University Press, 2005). 45. Anderson, Book Review, 111. 46. Ibid. 47. James Gillespie, ‘The Rockefeller Foundation, the Hookworm Campaign and a National Health Policy in Australia 1911–1930’, in Roy MacLeod and Donald Denoon (eds), Health and Healing in Tropical Australia and Papua New Guinea (Townsville: James Cook University of North Queensland, 1991), 64–87; Annie Stuart, ‘We Are All Hybrid Here: The Rockefeller Foundation, Dr Sylvester Lambert, and Hookworm in the South Pacific’, Health and History, 8 (1) (2006), 80–99. 48. Milton Lewis, Thorns on the Rose: The History of Sexually Transmitted Diseases in Australia in International Perspective (Canberra: Australian Govt Pub. Service, 1998). 49. Antje Kampf, Mapping Out the Venereal Wilderness: Public Health and STD in New Zealand 1920–1980 (Berlin: Lit., 2007). 50. Linda Bryder, A History of the “Unfortunate Experiment” at National Women’s Hospital (Auckland: Auckland University Press, 2009), reprinted as Linda Bryder, Women’s Bodies and Medical Science: An Inquiry into Cervical Cancer (London: Palgrave Macmillan, 2010). 51. Milton Lewis, ‘Introduction’, in J. H. L. Cumpston, Health and Disease in Australia: A History, ed. M. J. Lewis (Canberra: AGPS Press, 1989), 1, 2. 52. Peter Graeme Hobbins, ‘ “Outside the Institute There is a Desert”: The Tenuous Trajectories of Medical Research in Interwar Australia’, Medical History, 54 (2010), 1–28. 53. M. Anne Crowther and Marguerite W. Dupree, Medical Lives in the Age of Surgical Revolution (Cambridge/New York: Cambridge University Press, 2007), 278. 54. Philippa Mein Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia 1880–1950 (Basingstoke: Macmillan, 1997); Linda Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907–2000 (Auckland: Auckland University Press, 2003). 55. Stephen Garton, ‘Asylum Histories: Reconsidering Australia’s Lunatic Past’, in Catharine Coleborne and Dolly MacKinnon (eds), ‘Madness’ in Australia: Histories, Heritage and the Asylum (Perth, WA: API Network, Curtin University of Technology, 2003), 21.

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56. Barbara Brookes and Jane Thomson (eds), ‘Unfortunate Folk’: Essays on Mental Health Treatment, 1863–1992 (Dunedin: University of Otago Press, 2001); Angela McCarthy, ‘Ethnicity, Migration and the Lunatic Asylum, Early Twentieth Century Auckland, New Zealand’, Social History of Medicine 21 (2008), 47–65. 57. Catharine Coleborne, ‘Making “Mad” Populations in Settler Colonies: The Work of Law and Medicine in the Creation of the Colonial Asylum’, in Diane Kirby and Catharine Coleborne (eds), Law, History, Colonialism: The Reach of Empire (Manchester: Manchester University Press, 2001), 118.

Select Bibliography Anderson, Warwick, The Cultivation of Whiteness: Science, Health and Racial Destiny in Australia (New York: BasicBooks, 2003). Bashford, Alison, Imperial Hygiene: A Critical History of Colonialism, Nationalism and Public Health (New York: Palgrave Macmillan, 2004). Bryder, Linda, ‘A New World? Two hundred Years of Public Health in Australia and New Zealand’, in Dorothy Porter (ed.), The History of Public Health and the Modern State (Amsterdam: Routledge, 1994), 313–34. ——— , A Voice for Mothers: The Plunket Society and Infant Welfare 1907–2000 (Auckland: Auckland University Press, 2003). Coleborne, Catharine, and Dolly MacKinnon (eds), ‘Madness’ in Australia: Histories, Heritage and the Asylum (Perth, WA: API Network, Curtin University of Technology, 2003). Dow, Derek A., Maori Health and Government Policy 1840–1940 (Wellington: Victoria University Press in association with the Historical Branch, Department of Internal Affairs, 1999). Lange, Raeburn, May the People Live: A History of Maori Health Development 1900–1920 (Auckland: Auckland University Press, 1999). Lewis, Milton, Thorns on the Rose: The History of Sexually Transmitted Diseases in Australia in International Perspective (Canberra: Australian Govt Pub. Service, 1998). McCalman, Janet, Sex and Suffering: Women’s Health and a Women’s Hospital: The Royal Women’s Hospital, Melbourne, 1856–1996 (Carlton, Victoria: Melbourne University Press, 1998). Mein Smith, Philippa, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia 1880–1950 (Basingstoke: Macmillan, 1997). Raftery, Judith, Not Part of the Public: Non-Indigenous Policies and Practices and the Health of Indigenous South Australians 1836–1973 (Kent Town, South Australia: Wakefield Press, 2006). Sutphen, Mary P., and Bridie Andrews (eds), Medicine and Colonial Identity (London: Routledge, 2003).

pa rt i i i

THEMES AND M ET HODS

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chapter 18

childhood a n d a dol e scence a lysa l evene

The history of childhood is growing up. It is also growing outward, into histories of work, welfare, education, rights, value—and health. This expansion of the field is welcome, as the history of medical care for the young has previously been patchy. While research on concepts of childhood in the past and aspects of children’s lives such as welfare provision and employment have burgeoned in recent decades, that on their health and medical care has developed only in fits and starts. This is unfortunate, since the way that practitioners and parents treated children when they were ill can be particularly revealing of attitudes towards this large portion of the population. The health and wellbeing of the younger generation is also significant because it reflects a variety of wider societal concerns about national efficiency, confidence in medical practice, a healthy and well-balanced population, and the quality of social relations. Roger Cooter recognized this when he called in 1992 for child health to be joined up with wider concerns in the social history of medicine and childhood.1 His aim has been addressed insofar as research has expanded markedly in both volume and direction. Now it is time to develop this into a broader and more self-reflective context, returning to basic definitions and qualities of childhood and child health and asking what exactly we mean—and mean to elucidate—by working in this field. Although work on the health of children and adolescents has been somewhat disparate in focus, certain clear directions and areas of interest are evident. In several respects it has mirrored wider trends in the history of medicine, in that it began with an examination of formal encounters between children, institutions, and practitioners, and has widened outwards from there. The work of George Frederick Still, published in 1931, was particularly influential for setting out the growth of paediatrics as a formal discipline, for example, and Seidler’s 1989 and Loudon’s 1979–81 surveys of the growth of children’s hospitals and dispensaries for children, respectively, are still useful.2 Historical demography was another strong early influence: accurate infant death rates are comparatively easier to recover than those of adults and also serve as a proxy for health care, economic

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development, and infrastructure.3 In the 1980s and 1990s, research on child health broadened out to encompass the wider implications of physical well-being, most notably in the work of Floud, Wachter, and Gregory on heights (published in 1990), more recently updated and extended by Leunig and Voth, and others.4 These studies illustrated how diet and medical care in childhood can be literally measured in an anthropometric sense in terms of adult height outcomes. It is no coincidence that much of the information on heights comes from army records: preoccupations with fighting forces and children as the promise of future national strength and efficiency is another strand to emerge in the literature. Here, the implications of child health for adult well-being were again paramount, although there were also benefits for the mortality and morbidity of the young. This work is contextualized by late-nineteenth-century eugenic concerns about a healthy and ‘good-quality’ population, and the campaign for welfare reforms around the turn of that century. This strand of research intersects with that on maternal and child welfare, and considered inter alia vaccination, maternal education, and infant health clinics and milk depots, many of the more formal encounters between children, parents, and institutions or official bodies. Subsequent research moved outwards from this formal framework, although it kept a similar set of ideas about national strength and quality at its heart. This work has sought out encounters outside the immediately medicalized institution—or, alternatively, has sought to explain the medicalization of other areas of children’s lives such as schooling. Work by Bernard Harris, John Welshman, Harry Hendrick, and John Stewart in the British context, for example, has spotlighted child health within welfare work, the School Medical Service, and the home, illustrating the nature and spread of provision for health care and disease prevention—mental and physical—and also the way that children were regarded by authorities.5 These thematic preoccupations are well represented in Cooter’s 1992 edited collection of essays on children and medical welfare, In the Name of the Child, the first book (and conference) to bring together researchers working on child health.6 The shift of focus away from sickness and towards well-being also mirrors Harry Hendrick’s well-known conceptualization of a changed focus by doctors in the past from children’s bodies in the later nineteenth century, to their minds in the mid-twentieth.7 More recently this type of child-centred outlook has pervaded work on the more traditional hospital encounter as well. Elizabeth Lomax’s work on London’s Great Ormond Street Hospital remains a classic reference, but medical historians such as Andrea Tanner and Alysa Levene, Jonathan Reinarz and Andrew Williams have more recently begun to spotlight the child as patient, and to tease out the ways in which they were conceptualized and treated as users of the wider medical marketplace.8 Finally, a number of younger scholars are starting to challenge the implicit assumption that there is little to say about children and medicine prior to the nineteenth century. Traditional sources like advice books and autobiographies are being re-interrogated to unpick how and whether children were treated differently from adults. The findings show almost uniformly that doctors who wrote about treating children did make distinctions in their treatment, dosage, and understandings of disease pathways from their treatment of adults. Much of this work has tied the history of child health and well-being to contemporary preoccupations with fighting strength and populationist ambitions. However, another

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clear theme in the more recent historiography, and one that will be developed at greater length in the sections that follow, is the responsiveness of researchers to current social policy and clinical concerns. In fact, the impetus to study the health of the young at all may arise from current concepts relating to the value of childhood itself and to children’s rights to health and happiness. This tendency is seen most clearly in, for example, research on mental disability, diet, and patient-histories that place the child’s voice at centre stage—at the same time that governments are prioritizing social services for children and children’s rights. That historians are increasingly being called on to advise on policy indicates how valuable these intersections can be, and keeping current concerns in mind when studying the past can bring fruitful new viewpoints and lines of enquiry. However, we should beware of allowing policy-makers and clinicians to set the historiographical agenda, and thus risk making anachronistic judgements of health or treatment in the past. So far this has been an area where historians of children and childhood have been alert to tension, but it is likely to become increasingly pressing if historians continue to be asked to comment on current trends and policy. Most of the examples cited so far are from Britain, but the general trends in both historiography and current policy have been broadly similar in the wider European and North American context. The field is as yet too underdeveloped to be able to speak of meaningful trends of research in particular settings, but the focus on national efficiency and strength has been a particularly striking and unifying concern. Marijke Gijswijt Hofstra and Hilary Marland note how heavily it features in both the British and Dutch context, albeit interpreted slightly differently by different historians.9 It is clear that the national context is important, however, especially since the health of the young has so often been tied to wider social trends. In England, for example, Deborah Dwork has linked British wartime experiences to infant welfare.10 Similarly, British wartime evacuation placed a spotlight on the poor health status of many city children in the 1940s, and this shaped both the post-war health reforms and the thrust of historical studies. In the Netherlands, evacuation was not a large-scale phenomenon, but concerns about emotional deprivation and trauma came to the forefront in the aftermath of wartime occupation and the separation of so many families deemed undesirable by the occupation regime. Infant welfare clinics have loomed large in work on the French context because of early innovations in this area, spurred by humiliating military losses in the FrancoPrussian War, while in America a completely different context of health funding, insurance, and philanthropy has directed historians to welfare charities and the health of immigrant children.11 There is thus clearly a national flavour to work in different locales (and this extends also to local or culturally specific levels of analysis), but what is perhaps more notable is the convergence on certain key themes in the work to date. There are reasons to be optimistic that the study of children’s health and medicine is gathering momentum in a number of promising directions, and in ways that allow us to escape the narrow framework of hospital and clinic. This is less true of adolescents, however, who have had very little attention paid to them. This is partly because this is a low-risk period of life for morbidity and mortality. It is also due to a lack of certainty about who adolescents were in the past and, indeed, whether the life stage existed at all.

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Work on this age group has tended to focus on their relatively unproblematic status as workers, or on their higher profile among juvenile delinquents and criminals.12 This is a field of work particularly ripe for further development, as will be commented on further below. Discussions of infant health, by contrast, have abounded, albeit focusing mainly on mortality and maternal and infant welfare. Babies have not suffered from the same definitional problems as adolescents in the past, but work on this part of the young lifecourse has arguably not developed to the same extent as that on young children, and has not fully become a social history of infant health and ill-health. Early to develop but slow to mature, the history of infancy would also repay further work. Several trajectories and clusters of research can thus be drawn out of the work done to date on the history of child health. While much of it is instructive for the ways that we should think about child health and well-being in the past, there is a case for saying that we have not really addressed the underlying intellectual and methodological framework as a group.13 An obvious comparison to make is with women’s history, where feminism and maternalism have given considerable force and momentum to the field. A similar drive in childhood studies has arguably come only from sociological and anthropological concerns with child rights and entitlements. Instead, writers on the medical history of youth (which include medical practitioners as well as historians and social policy researchers) have in large part responded to source types and wider themes in social, economic, and medical history, or current policy, as noted already. Interests in health and well-being have emerged out of, or merged into, histories of welfare, education, national efficiency, and work, and themes like community care, state responsibilities, class relations, and the growth of medical institutions. This is partly because of the ubiquitous problems of children’s relative invisibility in historical records as users of medical services, and their lack of agency, decision-making, and self-reflection. Now that many of the institutional and ‘official’ sources of data have been mined at least to some extent, however, we are having to become more creative, and there is evidence of a greater attempt to work together on the intellectual problems that research in this field brings. Several UK universities have identified child health (broadly defined) as an area of active research, and international collaborations are also being set up. Despite this, however, current research interests are still informing the nature of collaboration, not always pausing even to debate whether we all mean the same thing when we talk of ‘child’ or ‘adolescent’ health. There is certainly room for more reflective work on the nature of child health and child doctoring.

Definitions of childhood and adolescence In today’s Western society childhood scarcely needs a definition. This phase of the life cycle is framed by a number of clearly discernible expectations: dependence on family/ guardians; full-time schooling; absence of work; and availability of play, for example. We are appalled when we hear that children are failed in any of these respects, as the media frenzy over high-profile abductions or neglect cases shows. The case of the British nineyear-old Shannon Matthews, who went missing in February 2008 but was later found to

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have been hidden by her mother and her mother’s partner in order to claim a reward, illustrates this particularly forcefully. Media coverage during the search period focused on the complex family situation (the adjective ‘dysfunctional’ was a common one), and turned to horror when the child was found and it emerged that her closest guardians had staged the abduction. The complicity of the mother in the scheme was a forceful further insult to a society that privileges childhood dependency, trust, and innocence. Other modern inversions of expectations about childhood have been received with equivalent disgust by the media—such as the Austrian Josef Fritzl or the American Philip Garrido, both of whom imprisoned children (in Fritzl’s case, his daughter) and fathered children by them. The links between these cases and historical debates on classbased attitudes to childcare, and value-laden assumptions as to blame and neglect, are also hard to ignore—as are the risks of applying current feelings about childhood to the past. At the same time, however, we are surrounded by evidence that we are unsuccessful at promoting the ideal of childhood we subscribe to so forcefully. Reports continually reveal that rates of depression in children in Western societies are high, that academic levels are stagnant, and that our shopping habits lead to the exploitation of child workers in developing countries. As noted above, one of the few disciplines that has dealt with intellectual and definitional problems of an aspect of childhood studies is the sociological consideration of children’s rights—not only to nurture and health, but to selfesteem and agency that might include working. It is clear that childhood is as culturally determined and complex today as it has ever been, but medical historians have generally been slow to appreciate that they must do their own unpacking of these labels. This is far from implying that historians of children and health fail to appreciate the ways that childhood has changed over time. This was a criticism of early work in this field: Philippe Ariès, for example, tacitly recognized to be the founding father of Western childhood studies, was accused of being ‘present-minded’ in his interpretation of past attitudes to children.14 Historians of childhood have, indeed, spent many pages of text debating how we should recognize this state in the past, and how we should interpret indicators of care, affection, and discipline.15 Historians of medicine have engaged with these debates, but they have not done much to further them, or to probe them more deeply in a specifically medical context. This is undoubtedly because the majority of work on child health has focused on the later nineteenth and twentieth centuries, a period when childhood was formally treated under the heading of paediatrics. In fact, Nicholas Orme shows us that definitions of childhood, youth, and infancy were clearly made in the medieval period and earlier.16 By the nineteenth century (the focus of much of the early work on child health and welfare), however, doctors had effectively done the work for us by defining their own remit, and there was little need for us to debate how this translated into different experiences of illness and care, or age-specific notions of diagnosis and disease processes. This has led to a lack of consideration of the nature of childhood and adolescence in this field. In this respect, bundling all youthful experiences of ill-health together under the label of paediatrics may be unhelpful. There are few other medical fields that are defined by their life stage as opposed to disease type or site (gerontology and perhaps obstetrics being the notable exceptions). Perhaps this way of defining young people as patients is disingenuous as it encourages us to view them

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primarily in terms of their age and not their experience of ill-health. We might make more insightful discoveries about the nature of child patients and disease by studying how they are treated compared with others experiencing similar impairment. Lest we throw the (properly conceptualized) baby out with the bathwater, however, it is worth pausing to note that there are several reasons why childhood and adolescence do provide a useful framework for analysis. Firstly, many of the more formal medical encounters for the young have traditionally taken place via locations where they are gathered by age (schools, workplaces, welfare institutions, and baby clinics). In these cases, youth is an important reference point for defining and delivering medical attention. Secondly, as these examples illustrate, some medical complaints are more common in childhood and so can scarcely be examined without due attention to this part of the life cycle. Many infectious diseases, such as measles and whooping cough, have attenuated over time to become relatively benign and ubiquitous childhood experiences. Other medical conditions like head lice are common among school-age children because they gather together in schools and nurseries and have freer physical contact with each other than do adults. Some procedures—like tonsillectomies—are associated with children because most people predisposed to problems have their tonsils removed when they are young. Thirdly, some of the most intensively studied areas of child health in the past are examined via a framework of youth, even if the condition itself is not specific to the life stage. An example here is the movement for national efficiency towards the end of the nineteenth century. This was a general concern about the state of society, but it was deflected towards children in particular because they could break the perceived move towards progressive degeneration over time. By investing in disease prevention and physical robustness for children, doctors and politicians could promote a healthier and stronger future. Many of the responses to this drive were delivered via schools and clinics, but here the focus on the young reveals wider social concerns rather than being narrowly focused on childhood in and of itself. These are all valuable reasons for singling out children and adolescents for particular study, but the point remains that we could do more to bear in mind both the theoretical challenges of studying one period of life in particular and the need to apply this to children as part of a wider patient body, not one segregated simply because of their age. Before returning to these considerations in the concluding comments, the following sections will take up two of the main thrusts of work in the field of child health to illustrate some of the themes introduced here. The first is the development of child-centred patient histories of the young; the second focuses on child health on the borders of ‘normal’ experience.

The child-centred patient perspective As already noted, one of the principal problems historians working on childhood must contend with is the scarcity of the child’s own voice. Most records were created by parents or medical attendants, and often give little evidence as to the child’s feelings, interpretations, or actions. This is progressively less true over time, as practitioners became

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more alert to child psychology and the need for self-expression and some sense of control, but the child patient’s voice and response is still much harder to find than that of adults. We inevitably see childhood sickness in relation to their dependent state because it was almost always mediated via adults’ perceptions and expectations. Given this fact, it is perhaps not surprising that so much of the history of child health is tied to notions of patriarchy, state control, and social engineering. This has not led to a neglect of children as patients—the young have featured quite heavily in responses to Roy Porter’s challenge for more patient-centred histories, no doubt partly because case notes and doctors’ reports are some of the most fertile types of records we have.17 However, to illustrate the point made above, we have not used them to theorize much about the nature of childhood disease, treatment, and cure. Of course, the fact that we are able to talk with some authority about the types of child patients in particular hospitals or clinics, their ages, cure rates, treatment regimens, even physical surroundings, is an enormous boost to our understandings of adults’ treatments of the young. However, they do little to further the notion of what is distinctive about the history of medicine for children or to link the idea of childhood with the reality of children’s sickness. One area of research where this is starting to be unpicked further is in early modern studies, where the assumption that paediatrics was a self-explanatory framework for exploring the health and ill-health of young patients is being challenged. The term ‘paediatrics’ to denote the study of infant and child health seems to have first emerged in print in the 1850s.18 University Chairs and learned journals were slower to emerge, but the field gradually gained critical mass in Western Europe and North America and started to self-identify as a separate specialism. Lisa Petermann’s analysis of the professionalization and specialization of paediatrics has done much to elucidate this process, but she draws attention to its longer-standing origins, identifying an era of ‘children’s medicine’ between 1762 and 1884 as distinct from a self-identified ‘paediatrics’. She defines this as a period where many of the subsequent indicators of professionalization were laid down, but which pre-dated the self-conceptualization that marked later developments.19 There was certainly a burgeoning market for child-care and medical advice for parents during the earlier phase, much of which paid attention to the different dosages and treatments required by children’s bodies and illness compared with those of adults.20 Doctors in the early modern period also seem to have appreciated how critical the mother’s care and attention was for child patients, which again distinguished their care from that of adults. Petermann makes this explicit in her consideration of a medical ‘triad’ of doctor, child, and parent (most commonly the mother). The need for family care was given as one of the reasons that children should not be admitted into general hospitals in the eighteenth century—and also for the support of outpatient dispensaries which would allow a sick mother to remain with her family. An emphasis on medical expertise had not yet outweighed the significance of maternal nurture, although doctors were increasingly styling themselves as the holders of scientific knowledge as the seventeenth and eighteenth centuries progressed. Nonetheless, the seemingly innumerable numbers of medical texts and advice books published in this period show how far they wanted to educate mothers in the ways of their children’s bodies—at least enough to know when to call the doctor.

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Another reason for the emphasis on maternal nurture for young patients in this period was the difficulty of caring for unaccompanied children in more formal settings like hospitals: children required more intensive supervision and active care than adult patients; they presented raised risks of spreading contagion; and it was harder to elicit a narrative of sickness and symptoms from them. Almost all hospital rules for eighteenthcentury English institutions stated that children (like pregnant women, certain infectious cases, and the mentally ill) could not be admitted except in medical emergencies or for surgical treatment. This much has been a part of historical orthodoxy for some time, but is now being investigated more critically. Levene, Reinarz, and Williams have analysed several sets of provincial hospital admissions registers for the eighteenth century and found that there was in fact a significant proportion of children among the patient body: an average of 13 per cent, with highs of 25 per cent at the Manchester Royal Infirmary.21 Some were surgical and emergency cases, but others were suffering from chronic or contagious diseases. Ritzmann likewise highlights the treatment of child surgical patients at the general hospital in Zurich during the same period.22 These studies show that children clearly were being treated in hospitals, but the lack of contemporary debate on their care or separate accommodation makes it unlikely that they were regarded as child patients rather than surgical or emergency patients. Case notes do not survive for the English institutions, although they do in the Zurich case, but one clear difference in the treatment of child patients in English towns was the increased use of outpatient care (the hospital in Manchester made particularly heavy use of this, which correlates with the higher incidence of children on the rolls there). Here again, it was the location of treatment and in particular its relationship with the family that distinguished children’s medical treatment in institutions during this period. Children were treated at outpatient dispensaries apparently without comment, which also reinforces the impression that doctors were not yet contemplating their status as requiring distinctive care in any large-scale way. The exception to this was George Armstrong’s eighteenthcentury ‘Dispensary for Poor Children’ in London, which seems to have been popular among the poor, but was short-lived.23 Generally, however, the impact of ‘proto-paediatric’ attention was almost certainly much greater among the lay readers of works by William Buchan, James Nelson, Michael Underwood, and the like than among hospital patients. This points to a dichotomy between the interest of individual author-practitioners and hospital doctors, even in this time of Enlightenment attention on childhood.24 In fact, Pelling points out that children had also been treated at London hospitals from the sixteenth century. One of those refounded at this time, Christ’s Hospital, catered specifically for the young, although more in a welfare and education capacity than a health one.25 We still largely lack the experiences of the child patients themselves for the early modern period, but it is clear that we can make moves towards a better understanding of the types of medical care and treatment they could access. We can also be more analytical in unpicking how they were regarded as a part of the patient body. This fits with a general move towards patient-centred approaches in the social history of medicine. This will be furthered by innovations in record linkage and availability, such as the online and publicly available database of patient records at several English and Scottish children’s hos-

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pitals.26 Andrea Tanner has already demonstrated its potential for accessing patients and their families’ feelings about hospital care—although the leitmotif of power relations and adult perceptions is likely to be difficult to avoid entirely.27 Adolescents have not really been singled out as patients in these types of histories. It is in fact only in very recent years that policy-makers and doctors have started to differentiate the medical care of adolescents, for example, by keeping them on their own wards. Emm Barnes has made a rare study of this differentiation in a revealing investigation of patient literature for young cancer sufferers in England.28 Teenage patients were previously treated either with adults or with younger children, but since the 1960s it has increasingly been recognized that they have different needs, concerns, and conceptualizations of their illness than either of these other groups. Adolescents are often still below the age where they can make medical decisions on their own behalf but they have a much greater need to feel in control than a young child. They are also more able to weigh up the realities of a prognosis and consequently have different sets of anxieties. Barnes’s study highlights some of these issues of self-concepts of health and sickness and how they are differentiated by age even among the young. This has clear links with developments in histories of child psychology and emotion, but serves particularly to illustrate the benefit of treating childhood as a period with subdivisions. Lutz Sauerteig has also delineated the changing focus of sex education literature in West Germany as a way in to conceptualizing gendered and medicalized views of developing bodies.29 This similarly fits into wider historiographical and social policy interest in anxieties about child sexualization and rebellion that have particularly crystallized around the teenage years.

Children and the borderland of normality A second theme to emerge in recent medical histories of childhood and youth is a focus on the boundaries of normal life experiences. Again, this is a trend in childhood studies more generally, where the problematized or ‘welfare child’ as an object of scrutiny has gained much attention.30 This child is often a liminal one: a delinquent, a runaway, exploited by employers, or in the care of welfare authorities. In the wider field, some of the medical encounters of the young can in themselves be regarded as liminal, since they are not ‘normal’ experiences and frequently indicate the family and the individual at a point of crisis and tension. Other experiences and procedures have become progressively normalized, such as vaccinations, which are now routine and delivered at school. We can identify even more peripheries within the social history of medicine where research is clustering, however. One of the central tenets to be developed here is the notion of a standard or normal childhood and the ways that writers and legislators privileged a particular ideal of the healthy and well-functioning young. There has been much written on the impact of class-based assumptions and aspirations on this idealized family, and

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many concur that it was an unrealistically middle-class ideal that the working classes could not, or did not, wish to match. As one notion of family life became the norm, others by the same process became ‘problematized’; precisely those whose children were judged to be neglected, filthy, dirty, full of contagion, and contributing to the problem of moral and physical degeneracy (so all-pervading is the notion of degeneracy and national fitness in this field).31 Medical historians have now started to penetrate beneath the idealized image to examine the children who ‘failed’ to meet expectations of health. This perspective is particularly acute for the period from the nineteenth century onwards, when scales and charts of normal development became popular. The Child Study Movement and other attempts to observe and quantify child growth and attainment further promoted the notion of normality and abnormality for contemporaries. Child-care manuals often contained development charts that could be filled in by parents, and the growth of medical inspection in schools and infant welfare and milk clinics in the early twentieth century provided further fodder to the notion of the quantifiability of healthy progress.32 Children were tested as they had never been previously, and while this could provide a measure of reassurance and pride for parents, educators, and legislators, it also set up standards that some failed to meet. Historians have taken up this focus by examining the child guidance movement, child psychology and psychiatry, and the history of physical incapacity, particularly in the twentieth century. The children in these groups had failed some expectation of fitness, and thus were on the edges of normalized expectations of childhood and child health. Typical juvenile behaviour like bed-wetting, masturbation, even novel-reading became redefined as indicators of deeper anxiety and dysfunction on a personal or family level. In the aftermath of the Second World War there was a particular focus on the promotion of ‘mental hygiene’, and emotional stability for the sake of the population’s current and future happiness and productivity. As Mark Jackson has put it in the context of a wider thesis about the ‘borderlands of imbecility’, child hygiene was ‘a crucial tactic in the battle against race suicide’, and ‘dull and backward’ or mildly ‘mentally deficient’ children were particularly threatening because they were harder to distinguish from the normal.33 This was translated into a different set of standards of healthiness in the late nineteenth and twentieth centuries—namely a stress on the well-balanced mind and the significance of the child’s relationships and influences. Harry Hendrick develops this further by trying to access children’s own emotions and responses to being sent to hospital in the 1950s—an era when parents were actively discouraged from visiting in England.34 More broadly, work in this field illustrates how locally and culturally specific were notions of mental normality: John Stewart points out how the growth of child guidance followed quite different paths in America, England, and Scotland despite a significant amount of cross-fertilization of ideas and methods, while Gijswijt-Hofstra and Marland point out the earlier focus on psychology and ab/sub/normality of childhood in the Netherlands than in England.35 This area of research pertains more than many others to older children and adolescents, even if specific reflection on the nature of adolescence and youth is still rare. Mark Jackson ties many of the concerns around mental disability specifically to the period of

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adolescence by making a link between the start of physical and sexual maturity and a threat to social norms and balance. An identical case could be made as to why adolescents loom so large in discussions on welfare and delinquency. In fact, Sarah Hayes makes the common basis of emotional maladjustment and delinquency in the young clear in her discussion of the medicalization of standards of normality.36 Another example is Gemma Blok’s case study of the Dutch therapeutic regime at Amstelland, where treatment and conceptualizations of adolescence in the 1960s were clearly articulated.37 She notes, however, that this forms part of an idealization of adolescence that was distinctive to the postSecond World War years. Although studies have traced the origins of concerns about this period of the life-course back into the early modern period and earlier, there is something of a consensus that they did not take a recognizably modern form until the mid-twentieth century, and their impact on health care was even longer in coming. This has arguably had as stifling an impact on the consideration of adolescence as the assumption that child health cannot be accessed before the era of paediatrics. Interest in the boundaries of mental ability and health is now starting to be matched by studies on physical impairment.38 These research agendas push forward our understanding of child experiences of health and ill-health, well-being, and disability, and they also make connections with wider concerns both in the past and today. This is the area where connections to modern policy and clinical concerns are clearest: is it any coincidence that work on troubled children has arisen at a time when we are concerned about levels of child contentment and anxiety in our own society? Similarly, recent debates about community, personal, and institutional care for mental illness is being echoed in the historical literature. Matthew Smith’s work on the historical origins and constructions of attention deficit hyperactivity disorder is a particularly fine illustration of the ways in which a modern process of medicalization and problematization is being matched in historical studies.39 As the attention of doctors in the past seems to have moved from bodies to minds, and from the normal to the supposedly not-normal, so too has our own.

Conclusion It is clear that childhood and youth have undergone a period of much more intensive scrutiny within the social history of medicine in the past few decades. Much of this has mirrored trends in the field more generally; for example, the broad shift away from environmental to personal health, from hospitals and clinics to patient histories and informal care. The benefits and risks of the links to modern preoccupations have been noted already, although historians have so far avoided allowing their research agenda to be unduly skewed in this way. Yet when reflecting on a collection of essays on child health edited by Marijke Gijswijt-Hofstra and Hilary Marland in 2003, Roger Cooter claimed that little progress had been made since the publication of the earlier collection In the Name of the Child in 1992.40 He pointed out that many of the same preoccupations remain: institutions, families, advice literature, child guidance, although he recognized

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that their treatment had become more nuanced and more heavily influenced by current thoughts on agency, power, delinquency, and emotions. Both of these collections approach child health from a specific angle, however, namely medical welfare and national fitness, respectively. Between them, they indicate the ways in which responses to child health in the past have been framed by historians and contemporaries. GijswijtHofstra and Marland themselves noted that the conference that produced their book also challenged the usefulness of some of these overarching ideas. They say, of the national efficiency theme, that it is ‘a concept which could be said to have been overused by historians as an explanatory model, and often with little subtlety’.41 There is now evidence for a clearer tendency to spotlight child health, treatment, and health in its own theoretical framework, however. It will always be difficult to access children’s own thoughts, feelings, and actions in the past, but recent work has been more thoughtful about how we might approach such issues. Historians are also starting to question how the health and sickness experiences of young people related to adult experiences, and how doctors conceptualized the young body and mind. The history of child health is moving from the margins of welfare and employment into its own field, and it is to be hoped that future work will continue to build up a more convincing set of theoretical reference points and challenge critically those that have been applied hitherto. Children’s health is now being examined in a variety of contexts, from hospitals and clinics through to family and community care. There is still more to be done on the specifics of curative medicine, however, and how this relates to conceptualizations of children’s bodies. The child’s experience as a consumer within the medical marketplace (either as an individual or—more likely—via parents) also deserves further consideration, and one that moves beyond the state–family dichotomy. How comprehensive was the range of health care options open to children, and how far was it distinguished from that of adults? How and why did some areas of medicine concentrate into paediatric sub-specialisms and what does this tell us about children more broadly? Sources for the early modern and medieval periods deserve further interrogation. Work in osteo-archaeology is already showing the potential to transfer some of these thoughts and themes much further back in time.42 In these earlier periods, we must be directed by source availability, but it is encouraging to note that new research is looking outside the places where children are gathered together by age and examining their health status alongside adults’ as well as separately. Again, this calls for greater rigour in delineating what we and contemporaries mean and meant by childhood, and how this was differentiated from infancy to late teens. Finally, it is apparent that the history of child health is still focused largely on the European, and particularly the Anglophone, context, and the range of genuinely comparative work even within this field is narrow.43 It is clear that while there were common trends in conceptualizations and treatments of child health in Western countries, there were also differences that would repay further investigation. This narrow geographical focus is not shared in the wider social history of medicine where extraEuropean medical regimes are being actively explored. It is to be hoped that childhood studies will make the transition that has hitherto belonged almost exclusively to anthro-

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pology.44 It will bring new challenges for the history of child health, but should be of enormous benefit to considerations of what it means to be a child patient, to experience ill-health, or disability, and how this relates to agency, minority, the family, rights, doctoring, and nursing. As Hugh Cunningham has put it, we need something with which to contrast our understanding of childhood in order to understand it: ‘ “[t]he other children” could only be so-named, and so-imagined, when there was a firmer notion of “the children” and of what childhood should be’.45 In medical histories this has a double resonance: child health must be defined against unhealthiness; and ideas of health in one place or time should be defined against those elsewhere and at different times. By doing this, we will reach a more reflective and robust understanding of the states of health and disease in childhood and adolescence in the past.

Notes 1. R. Cooter, ‘Introduction’, in idem (ed.), In the Name of the Child: Health and Welfare, 1880– 1940 (London: Routledge, 1992), 1–18. 2. G. F. Still, The History of Paediatrics (London: Oxford University Press, 1931); E. Seidler, ‘An Historical Survey of Children’s Hospitals’, in L. Granshaw and R. Porter (eds), The Hospital in History (London: Routledge, 1989), 181–98; I. Loudon, ‘The Origins and Growth of the Dispensary Movement in England’, Bulletin of the History of Medicine 55 (3) (1981), 322–42; Irvine Loudon, ‘John Bunnell Davis and the Universal Dispensary for Children’, British Medical Journal 1 (6172) (5 May 1979), 1191–4. 3. For example, see C. Corsini and P. P. Viazzo (eds), The Decline of Infant and Child Mortality: The European Experience, 1750–1990 (The Hague: Martinus Nijhoff, 1997); A. Bideau, B. Desjardins, and H. Pérez Brignoli (eds), Infant and Child Mortality in the Past (Oxford: Clarendon Press, 1997). On the calculation of infant mortality rates, see E. A. Wrigley and R. S. Schofield, The Population History of England 1541–1871: A Reconstruction (London: Edward Arnold, 1981), 210–13. 4. R. S. Floud, K. W. Wachter, and A. Gregory, Height, Health and History: Nutritional Status in the United Kingdom, 1750–1980 (Cambridge: Cambridge University Press, 1990); Peter Razzell, ‘Did Smallpox Reduce Heights?’, Economic History Review 51 (2) (1998), 351–59, and the rejoinder by T. Leunig and H. J. Voth, ‘Did Smallpox Reduce Height? Stature and the Standard of Living in London, 1770–1873’, Economic History Review 49 (2) (1996), 541–60. See also Bernard Harris, ‘Essay Review. Health, Height and History: An Overview of Recent Developments in Anthropometric History’, Social History of Medicine 7 (2) (1994), 297–320. 5. B. Harris, The Health of the School Child: A History of the School Medical Service in England and Wales (Buckingham: Open University Press, 1995); J Welshman, ‘School Meals and Milk in England and Wales, 1906–45’, Medical History 41 (1997), 6–29; John Stewart, ‘The Campaign for School Meals in Edwardian Scotland’, in Jon Lawrence and Pat Starkey (eds), Child Welfare and Social Action in the Nineteenth and Twentieth Centuries: International Perspectives (Liverpool: Liverpool University Press, 2001), 174–94; Harry Hendrick, ‘Child Labour, Medical Capital and the School Medical Service, c.1890–1918’, in Cooter (ed.), In the Name of the Child, 45–71. 6. Cooter (ed.), In the Name of the Child.

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7. H. Hendrick, Child Welfare: Historical Dimensions, Contemporary Debate (rev. edn, Bristol: Policy Press, 2003). 8. E. Lomax, Small and Special: The Development of Hospitals for Children in Victorian Britain (London: Wellcome Institute for the History of Medicine, 1996); Andrea Tanner, ‘Choice and the Children’s Hospital: Great Ormond Street Hospital Patients and Their Families 1855–1900’, in Anne Borsay and Peter Shapely (eds), Medicine, Charity and Mutual Aid: The Consumption of Health and Welfare in Britain, c. 1550–1950 (Aldershot: Ashgate, 2007), 135–61; A. Levene, J. Reinarz, and A. Williams, ‘Child Patients, Hospitals and the Home in Eighteenth-Century England’ (Family and Community History, forthcoming). 9. Individual interpretations of the term ‘national efficiency’ seem to have been as important as differences in national settings: Marijke Gijswijt-Hofstra and Hilary Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam/New York: Rodopi Press, 2003), 7–30. 10. Deborah Dwork, War is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England 1898–1918 (London: Tavistock, 1986). 11. Deborah Dwork, ‘Childhood’, in W. F. Bynum and Roy Porter (eds), Companion Encyclopedia of the History of Medicine, Vol. 2 (London: Routledge, 1997), 1072–89; G. F. McCleary, The Early History of the Infant Welfare Movement (London: H. K. Lewis, 1933); Judith Sealander, The Failed Century of the Child: Governing America’s Young in the Twentieth Century (Cambridge: Cambridge University Press, 2003); Kathleen W. Jones, Taming the Troublesome Child: American Families, Child Guidance and the Limits of Psychiatric Authority (Cambridge, MA/London: Harvard University Press, 2002). 12. Victor Bailey, Delinquency and Citizenship: Reclaiming the Young Offender 1914–1948 (Oxford: Clarendon Press, 1987); Stephen Humphries, Hooligans or Rebels? An Oral History of Working-Class Childhood and Youth, 1889–1939 (Oxford: Blackwell, 1981); Peter King, ‘The Rise of Juvenile Delinquency in England 1780–1840: Changing Patterns of Perception and Prosecution’, Past and Present 160 (1998), 116–66. For a broader treatment, see J. Gillis, Youth and History: Tradition and Change in European Age Relations, 1770Present (New York: Academic Press, 1981). 13. See R. Cooter, ‘After Death/After-“Life”: The Social History of Medicine in PostPostmodernity’, Social History of Medicine 20 (3) (2007), 441–64. 14. Philippe Ariès, Centuries of Childhood (English trans., Harmondsworth: Penguin, 1962). 15. Linda Pollock, Forgotten Children: Parent-Child Relations from 1500–1900 (Cambridge: Cambridge University Press, 1983); Hugh Cunningham, Children and Childhood in Western Society since 1500 (2nd edn, Harlow: Pearson Longman, 2005); Harry Hendrick, ‘Constructions and Reconstructions of British Childhood: An Interpretative Survey, 1800 to the Present’, in A. James and A. Prout (eds), Constructing and Reconstructing Childhood: Contemporary Issues in the Sociological Study of Childhood (London: Falmer, 1990), 35–59. 16. N. Orme, Medieval Children (New Haven: Yale University Press, 2003), 3–10. 17. Roy Porter, ‘The Patient’s View: Doing Medical History from Below’, Theory and Society, 14 (1985), 175–98. 18. Its first listing was in a medical lexicon in 1857, and it appeared in The Lancet for the first time two years later (http://dictionary.oed.com). 19. Lisa W. Petermann, ‘From a Cough to a Coffin: The Child’s Medical Experience in Britain and France, 1762–1884’, PhD thesis, University of Warwick, 2007, 206–48 and esp. 207. The period of ‘children’s medicine’ is further divided into a ‘foundation phase’ and a ‘protopaediatric’ phase, dividing in 1830 with the foundation of the first university Chair in

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20.

21. 22. 23. 24. 25. 26.

27.

28. 29.

30. 31.

32.

33.

34.

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children’s medicine in Paris. See also Sammuel Kottek, ‘ “Citizens! Do you Want Children’s Doctors?” An Early Vindication of “Paediatric” Specialists’, Medical History, 35 (1) (1991), 103–16. A. N. Williams and R. Sunderland, ‘Thomas Willis—The First Paediatric Neurologist?’, Archives of Disease in Childhoold, 85 (2001), 506–9; A. N. Williams, ‘ “Labor Improbus Omnia Vincit” Ambrose Pare and Sixteenth Century Child Care’, Archives of Disease in Childhood, 88 (2003), 985–9; H. Newton, ‘The Sick Child in England, c.1580–1720’, PhD thesis, University of Exeter, 2010. Levene, Reinarz, and Williams, ‘Child Patients’. I. Ritzmann, ‘The Care of Injured Children in Eighteenth-Century Zurich’, (unpublished paper). Loudon, ‘John Bunnell Davis’. This phrase is Petermann’s—see the comments in n. 19 above. M. Pelling, The Common Lot: Sickness, Medical Occupations and the Urban Poor in Early Modern England (London: Longman, 1998), 107. See http://hharp.org/ (the Historic Hospital Admission Records Project). The project was funded by the Wellcome Trust, the Friends of Great Ormond Street Hospital, the Nuffield Foundation, and the History Research Unit at Kingston University. Tanner, ‘Choice and the Children’s Hospital’; Andrea Tanner, ‘The Great Ormond Street Historical Patient Database Project’, Archives: The Journal of the British Records Association, 28 (109) (2003), 132–41. E. Barnes, ‘Captain Chemo and Mr Wiggly: Patient Information for Children with Cancer in the Late Twentieth Century’, Social History of Medicine, 19(3) (2006), 501–19. Lutz D. H. Sauerteig, ‘Pregnancy and Childbirth in (West) German Books, 1900s–1970s’, in Lutz D. H. Sauerteig and Roger Davidson (eds), Shaping Sexual Knowledge: A Cultural History of Sex Education in Twentieth-Century Europe (London: Routledge, 2007), 129–60. See also the editors’ Introduction in the same volume for the wider context. A. Levene, ‘Family Breakdown and the “Welfare Child” in Nineteenth-and TwentiethCentury Britain’, History of the Family, 11 (2006), 67–79. On the ‘problematization’ of the working-class family, see J. Welshman, ‘In Search of the “Problem Family”: Public Health and Social Work in England and Wales, 1940–70’, Social History of Medicine, 9 (3) (1996), 448–65. Harris, The Health of the School Child; Lyubov G. Gurjeva, ‘Child Health, Commerce and Family Values: The Domestic Production of the Middle Class in Late-Nineteenth and Early-Twentieth Century Britain’, in Gijswijt-Hofstra and Marland (eds), Cultures of Child Health, 103–25. See also Lyubov G. Gurjeva, ‘Everyday Bourgeois Science: The Scientific Management of Children in Britain, 1880–1914’, PhD thesis, University of Cambridge, 1998. Mark Jackson, ‘ “Grown-up Children”: Understandings of Health and Mental Deficiency in Edwardian England’, in Gijswijt-Hofstra and Marland (eds), Cultures of Child Health, 141–60, at 157; Mark Jackson, The Borderland of Imbecility: Medicine, Society and the Fabrication of the Feeble Mind in Late Victorian and Edwardian England (Manchester: Manchester University Press, 2000). Harry Hendrick, ‘Children’s Emotional Well-being and Mental Health in Early PostSecond World War Britain: The Case of Unrestricted Hospital Visiting’, in Gijswijt-Hofstra and Marland (eds), Cultures of Child Health, 213–42.

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35. John Stewart, ‘Child Guidance in Interwar Scotland: International Influences and Domestic Concerns’, Bulletin of the History of Medicine, 80 (3) (2006), 513–39; M. GijswijtHofstra and H. Marland, ‘Cultures of Child Health in Britain and the Netherlands in the Twentieth Century’, in Gijswijt-Hofstra and Marland (eds), Cultures of Child Health, 7–30. 36. Sarah Hayes, ‘ “Rabbits and Rebels”: The Medicalisation of Maladjusted Children in MidTwentieth Century Britain’, in M. Jackson (ed.), Health and the Modern Home (New York/ London: Routledge, 2007), 128–52. 37. Gemma Blok, ‘Tall, Spanking People: the Idealisation of Adolescents in a Dutch Therapeutic Community’, in Gijswijt-Hofstra and Marland (eds), Cultures of Child Health, 265–86. 38. For example, S. Humphries and P. Gordon, Out of Sight: The Experience of Disability 1900– 1950 (Plymouth: Northcote House, 1992); H. J. Stiker, A History of Disability, trans. William Sayers (Ann Arbor: Michigan University Press, 1999); A. Borsay, Disability and Social Policy in Britain since 1750: A History of Exclusion (Basingstoke: Palgrave Macmillan, 2004). 39. Matthew Smith, ‘Hyperactivity and American Psychiatry 1957–80’, Social History of Medicine, 2 (3) (2008), 541–59. 40. R. Cooter, ‘In the Name of the Child Beyond’, in Gijswijt-Hofstra and Marland (eds), Cultures of Child Health, 287. 41. Gijswijt-Hofstra and Marland, ‘Cultures of Child Health’, 15. 42. Mary E. Lewis, The Bioarchaeology of Children: Perspectives from Biological and Forensic Anthropology (Cambridge: Cambridge University Press, 2007). 43. This was also pointed out in 2003 by Cooter, ‘In the Name of the Child Beyond’, 293. 44. A rare exception is Jennifer Beinart, ‘Darkly through a Lens: Changing Perceptions of the African Child in Sickness and Health, 1900–1945’, in Cooter (ed.), In the Name of the Child, 220–43. 45. H. Cunningham, ‘ “The Children” and “the Other Children”: Dualism in the Social Construction of Childhood’, Newsletter, Society for the History of Childhood and Youth, 10 (Summer 2007), available at http://www.history.vt.edu/Jones/SHCY/Newsletter10/ Cunningham.html, accessed 6 Feb 2009.

Select Bibliography Cooter, Roger (ed.), In the Name of the Child: Health and Welfare, 1880–1940 (London: Routledge, 1992). Dwork, Deborah, War is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England 1898–1918 (London: Tavistock Publications, 1986). Gijswijt-Hofstra, Marijke, and Hilary Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam/New York: Rodopi, 2003). Harris, Bernard, The Health of the School Child: A History of the School Medical Service in England and Wales (Buckingham: Open University Press, 1995). Hendrick, Harry, Child Welfare: Historical Dimensions, Contemporary Debate (rev. edn, Bristol: Policy Press, 2003).

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Jackson, Mark, The Borderland of Imbecility: Medicine, Society and the Fabrication of the Feeble Mind in Late Victorian and Edwardian England (Manchester: Manchester University Press, 2000). Levene, Alysa, ‘Family Breakdown and the “Welfare Child” in Nineteenth- and TwentiethCentury Britain’, History of the Family, 11 (2006), 67–79. Lomax, Elizabeth, Small and Special: The Development of Hospitals for Children in Victorian Britain (London: Wellcome Institute for the History of Medicine, 1996). Porter, Roy, ‘The Patient’s View: Doing Medical History from Below’, Theory and Society, 14 (1985), 175–98. Welshman, John, ‘In Search of the “Problem Family”: Public Health and Social Work in England and Wales, 1940–70’, Social History of Medicine 9 (3) (1996), 448–65.

chapter 19

m edici n e a n d old age s usannah o ttaway

In contemporary society, there is a widespread sense that old age and medicine go hand in hand. Debates about health care often centre on the disproportionate costs of medical care for the elderly; medical ethicists grapple with the efficacy of euthanasia; and in many Western societies, older people are hospitalized and institutionalized at vastly disproportionate rates. In some senses, this medicalized view of old age is inevitable: health problems do peak in later life, as organs fail, joints seize, bones decay, and teeth loosen. On the other hand, the relationship between old age and health has a distinct history, and was understood and addressed in disparate ways by societies in the past. We can consider, for example, two very different representations of the experience of health in old age to illustrate the diverse ways in which societies of the past conceptualized a ‘good’ old age, thereby shedding light as well on marked continuities in the identification of age-specific problems. In a 1787 funeral sermon for Mrs. Elizabeth French of Moreton-Hampstead, England, the preacher Jacob Isaac dwelt on the biblical concept of the ‘good old age’, exemplified by Abraham.1 This model of ageing revolved around acts of kindness, charity, and piety committed within a framework of certainty of salvation through God’s grace. Mrs. French’s life, as eulogized by Isaac, exemplified these qualities and was held up as a model of usefulness and ‘unruffled content’. Thanks to her ‘good constitution’ in old age, she survived into her eighty-seventh year. On this note, however, the modern reader must pause, for the assertion of constitutional hardiness is at striking odds with a footnote near the end of the text, which informs the reader that French was confined to her house by a palsy for the last eleven years of her life, and that she had been crippled for five years previous to that. The author disregarded French’s suffering in order to focus on her utility to her religious community, and, indeed, this footnote—signalled by an asterisk in the text—was probably not articulated in the oral delivery of the sermon. In this, Jacob Isaac’s work was typical of his eighteenth-century contemporaries’ lack of attention to the last, debilitated stage of old age. Overall, this sermon paints an extremely optimistic view and displays little interest in the medical situation of this old woman’s decline.

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Mrs. French’s case is typical of a historical silence about the loss of mobility in old age, especially among older women, before the Industrial Age. The old man’s staff is a standard prop in images of the elderly male, but the older woman’s loss of mobility is almost never discussed in early modern or medieval sources, neither in published nor private accounts, nor in visual sources. We know that loss of mobility was a reality, and that the disabled did sometimes use wheeled chairs to compensate. Lady Isabella Wentworth, for example, in the early eighteenth century, when she was in her seventies, describes, in a letter to her son, how she shifted between two different types of wheelchairs: ‘it is tereble Cold frosty wether . . . I am gott into my winter Quarters this morning for my Wicker chaer is warmer much then my wheel one.’ But even here, we note that this is the sole mention, among hundreds of letters, of her immobility, and it is an oblique reference indeed.2 We can compare the case of Mrs. French to that of the descriptions of older women left by Beatrice Webb (1858–1943), the early-twentieth-century historian and Labour politician. Webb’s diary and letters from the 1930s contain numerous descriptions of older friends and acquaintances. One friend was described: ‘As a woman verging on seventy, she seems as charming to me as a young one thirty years ago. She used to be good to look at—so she is at present, as a somewhat withered flower; if the form is crippled and movements infirm, there is the same charm of expression.’ Another friend, aged eightyfour, was described in much bleaker terms: Louise is hopelessly crippled and creeps about the house. Her mind is clear and old age and helplessness have softened her outlook on the world . . . but she is desperately lonely and bored with existence . . . The plain truth is that the aged feel that their children and some of their friends are thinking about: ‘If you are not enjoying life, why don’t you die and be done with it’. And the old person may feel that there is no answer, except that he does not want to die or does not see any comfortable way of doing it.3

Webb, in both of these cases, addresses the problem of mobility in old age head-on. In addition, she depicts the problems of ageing in an entirely secular vein, emphasizing the medical, physiological plight of her friends. A century after Mrs. French’s death, these sources help us to see that there has been a shift to a view of old age that is more centred on the medical than the religious context of ageing. These disparate cases speak to the major questions that this chapter will address as it traces the ways that medical understanding of the ageing process, while exhibiting major aspects of continuity, changed over time. What were the expectations and realities concerning the span of human life in the past? How did ideas about the ageing body affect attitudes towards health and longevity in later life? What remedies for the problems of old age were sought? What were the extents and limits of medical intervention in the later stages of life? The history of old age is relatively new, but this essay will also discuss the directions that historians of old age and health have taken in exploring this field. Although this chapter will focus primarily on the history of ageing in the West, some points of comparison with other cultures will also be introduced.

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Longevity One of the most important topics of concern to medical writers and practitioners throughout the ages has been the limits and possible extension of the human life span. How long were humans expected to live in the past and how did such expectations change over time with changing conceptions of the life course? Discussions of the natural extent of human life, as well as analysis of actual life expectancy in the past, has been a preoccupation of historians of ageing and historical demographers for the past few decades. In the 1970s and 1980s, especially, impressive quantitative analyses of historical records in France and England, as well as smaller community and regional studies, identified average life expectancies across the early modern and modern eras. More recently, demographers and statisticians, as well as historians of medicine, have been preoccupied with the question of the limits of human longevity, with some arguing an almost limitless potential for prolonging life, and others focused more on the age of about 100 or 120 as the limit to the natural human lifespan. Such debates are not new; rather, medical writers have debated the same issue throughout written history.4 Extremely long lifespans were reported in both classical and biblical texts, most famously in the case of Methuselah, who was supposed to have lived for 969 years (Gen. 5:21–7). Mythical figures like Tithonus, Tiresias, and the Sibyls were believed to have lived for centuries, and Homer gives us the classical example of Nestor, the sage King of Pylos; Nestor outlived three generations and his longevity and sagacity became a touchstone for the medieval and early modern worlds.5 Beyond these myths and exaggerated tales of great old age lies what has often been seen as a startling reality: expectations of old age in the distant past were not as different from modern times as might be expected. Even in the classical period, death before the age of sixty was considered to be ‘a harsh and unnatural fate’.6 And the medieval and early modern eras often used the biblical expression of life expectancy as a touchstone not so much for the mark of what all would reach, but of what was considered appropriate or ideal (Ps. 90:10 sets the lifespan at ‘three score and ten’ years). Shulamith Shahar has argued that ‘Contrary to the accepted view that people in the Middle Ages and the Renaissance were considered old from their forties, in fact they were classified as old between the ages of 60 and 70.’7 While some historians have thus used the age of sixty as the starting point for old age, others have argued, using evidence regarding the poor, that old age in the early modern period was usually perceived as starting earlier than that, especially for women, with the age of fifty serving as a more common marker, when the physical signs of menopause would be manifest. Although such work offers a caution to historians to consider the earlier ageing of the poor, compared with the elite who wrote most of the sources from this era, most historians do agree that the age of sixty was commonly used as a chronological signifier of old age. By the eighteenth century, at any rate, the use of the age of sixty as the marker for the onset of old age in both

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men and women was well established and has continued to serve as a standard into the modern period.8 Demographic studies, while necessarily tentative in pre-industrial, pre-Census times, demonstrate the existence of people over the age of sixty in all populations. It has been estimated that the Roman Empire in the first century ce had a population that was 6–8 per cent over the age of sixty. In medieval Europe, as well, people who lived through the dangerous early stages of life ‘had a fair chance of reaching the age of 60 or 70’. Here, too, although the demographic data are scarce, estimates are that the elderly accounted for 5 to 8 per cent of the population. The proportions shifted in the early modern era, as the increase in birth rate in the sixteenth century pushed down the proportion of elderly in Europe (to 5.5 per cent aged over sixty in Austria in 1632, for example), a state of affairs that was reversed by the later seventeenth century, when it appears that the percentage of the population aged sixty and over hovered around 10 per cent in several regions of Europe.9 With the nineteenth-century demographic transition, however, this trend was reversed again, and it would not be until the early twentieth century that the elderly would again rise to this high a proportion of Europe’s population. It should be noted, however, that different countries aged at very different rates, and their populations thus exhibited distinct age structures. The percentage of those aged more than sixty years in the USA increased from 4 per cent in 1830 to 6.4 per cent in 1906. By contrast, in France this age group was 8.7 per cent in 1801, and it rose to 12.6 per cent in 1906. In England those aged sixty and up were at 6–7 per cent of the population by the end of the eighteenth century and remained at that proportion until the early twentieth century.10 Despite all of these differences, it remains the case that the twentieth century has witnessed a transformation in life expectancy across European countries, a phenomenon often seen as the ‘greying’ of Western societies. One of the clearest indications of this shift, though also the most imprecise, is the overall increase in life expectancy in the world population, which went from 22 at the beginning of the Common Era, to 27 in 1750, 35 in 1950, and finally 58 in 2000. If we look more closely at changes in life expectancy in the twentieth century, we can see that this uptick in longevity is very recent indeed in many locations. In Brazil, for example, life expectancy at birth was age 50.9 as recently as 1950–5, but stood at 68.3 in 2000–5; Pakistan, too, made huge strides in the same period, rising from 41 to 61 years of life. China had an even more dramatic jump in life expectancy, shifting from 40.8 to 71.2 years over the same decades. In contrast, Western European nations had generally already started on the path to longer life before the second half of the twentieth century. Thus, by 1950–5, life expectancy was already over 65 in France, Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom.11 Major changes in the demographic experience of old age in the twentieth century were not limited to the expansion of life. Ageing in developed countries, as well as in many undeveloped regions, was also transformed by the lessening of the period of dependency and ill-health in the years before death. Medical interventions in the chronic diseases common to old age were only a part of this change, which was driven as well by enhanced nutrition and improved preventative care throughout life.12 Overall,

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then, the general expectations of length of life were remarkably consistent throughout Western history up until the last century, with a particular focus on the age of sixty as the entry point to old age. Although there was clearly a sense of great vulnerability to illhealth and early death, from the classical age onwards the human lifespan was presumed to extend ideally into the sixties and even seventies.

Medical conceptions of the ageing process Classical explanations of the ageing process attributed it to the loss of heat and fluid over the life-course; the older one became, the colder and dryer one was. Ancient physicians and medical writers based their theories of health on the balance of the four humours: blood, yellow bile, black bile, and phlegm were supposed to achieve a balance that matched the inherent tendencies and personality of the individual, as well as adhering to more universal principles of health. A person’s organs dried out as he or she aged, and one’s humours became imbalanced, with the blood and yellow bile declining and phlegm and black bile thus becoming more dominant. Hippocrates did offer an alternative theory, which was that ageing produced colder and wetter, rather than dryer bodies. Galenic theory focused only on the former theory, however, arguing that the appearance of greater moisture in old people (drooling, phlegm, and so on) was not indicative of innate dampness. In some texts, the very blood of older people was believed to be different from that of the younger: thinner, colder, and less abundant than in youth. This view of old age as colder also fitted into Pythagorean concepts of old age as winter in the four seasons of life. Aristotle held that physical disabilities declined earlier than mental ones, but in both cases, ageing past the middle, perfect, stage of life was envisioned as a decline.13 These classical theories continued to hold sway at least until the seventeenth century. Hence, throughout the medieval and Renaissance eras, ‘changes in the composition of the humours in the body—that is, the increase of external bad humours and a decrease in natural heat and innate radical moisture—were regarded as the immediate cause of all the accidentia senectutis, which included both physical and mental elements.’14 New medical understanding that arose during the scientific revolution of the seventeenth century did affect the understanding of ageing, but there was no radical or sudden abandonment of Galenic views of the ageing process, even in the face of the radical new views of writers such as the sixteenth-century alchemist Paracelsus (1493–1542) or the English physician William Harvey (1578–1657). Medical treatises as well as personal papers from the seventeenth century identified familiar diseases associated with old age: eye ailments, aching joints, tooth pain, palsy, weak heart, rheumatism, and general weakness. At the same time, however, medical tracts of the period did not generally identify these ailments as belonging particularly to the elderly, so this age group tends to be mentioned in passing, or by inference, and there was little medical interest in the problems of old age per se.15

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Still, early modern sources do reveal assumptions about the medical process of ageing. Patrick Ker’s ‘Meditation IV. Of Old Age’ in The Map of Man’s Misery reveals a familiar reprise of the health issues of the elderly. He describes the old man as: His Head and Joints shake; his Face is decay’d and full of wrinkles; his Eyes dim and cannot see; his Ears deaf and cannot hear; his Breath stinks, his Teeth are rotten, and cannot keep in his Spittle; his strength turn’d to weakness; his health to sickness, and his whole Body to a cluster of Maladies.16

Medical views of the ageing process in the eighteenth century reveal both continuity, in the prevalence of humoral theory and the likening of old age to a disease, and change, in a generally more optimistic view about a person’s ability to hold off the ill effects of ageing for long periods of time and in newly commercialized attitudes towards marketing cures for the discomforts of old age.17 Medical texts could exhibit all of these traits, as well as reflecting the influence of Enlightenment empiricism. A good example of the latter is A New Method of Treating Consumptions (1727), written by Nicholas Robinson (c.1697–1775). Robinson’s book on consumption laid out the differences between ‘Decays that naturally attend Old Age’ and the wasting caused by consumption. Whereas Aristotle had identified old age as a sort of middle ground between health and illness, Robinson distinguished between illness and old age more specifically, contrasting the rapid onset of ‘symptoms’ of consumption, and the gradual decline and progressive muscular atrophy in the ‘decrepidness’ of old age. We can clearly see the influence of new scientific methods on Robinson’s thinking from his Introduction, in which he states that the basis of his theories on consumptions ‘are a kind of Mathematical Reasoning, without Numbers, wherein the first Proposition is a Data consisting of self-evident Principles’.18 Robinson’s discussion of old age is based not on the writings of previous medical authorities, but on his observations of human bodies (dead and alive), seen through the lens of the most up-to-date understanding of medicine. Though there are still elements of humoral physiology, the most important set of assumptions comes from a modern understanding of the nature of the circulation and regulation of fluids in the human body. This change helps to explain why, according to Robinson, ageing is characterized by gradual muscular atrophy, rather than by a humoral change towards coldness and dryness. The nineteenth century brought new approaches to medical understandings and treatment of old age, as well as new physical challenges associated with the era of industrialization. Nineteenth-century medical texts were mixed in their level of attention to the elderly, with little interest in dire respiratory diseases and cancer, but new understanding of the physiology of ageing. These developments, spearheaded by physicians in Edinburgh, among others, began the important process of recognizing the study of the medical needs of the elderly as a discrete but crucial area for medical training. On the other hand, there were distinct limits to such advances. Heart disease, for example, was still not associated with old age, because ‘organic atrophy’ was seen as characteristic of ageing and neither the heart nor the kidneys were subject to atrophy. It was not until the twentieth century that heart disease among the aged was perceived as a particular

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problem. Still, Scottish physicians like George Day (1815–72) wrote important treatises on Diseases of Advanced Life, including descriptions of senile dementia.19 While still fatalistic about the medical situation of the elderly, mid-nineteenth-century Western Europe did witness an expansion of medical facilities and approaches that surely had some effect on the treatment of the aged. Even so, many historians have noted the lag in provision of medical energy and resources to the aged in England, in contrast to the growth of geriatric medicine in nineteenth-century France, especially the innovative work of J. M. Charcot (1825–93).20 The reason for this early emergence of medicine for old age in France in the nineteenth century was likely the early ageing of its population; we recall that France’s demographic history shows one of the earliest examples of population ageing, with the proportion of people aged over sixty growing from 8.5 to 12.5 over the nineteenth century.21 In Germany, despite the advanced work on old age by doctors such as Carl Canstatt, a fatalistic attitude towards illness in old age was still evident. For example, in the later nineteenth century the ‘cause-of-death category of “age-related infirmity” for the elderly actually increased, suggesting that doctors, and presumably patients too, were quite happy with the concept of a natural, unavoidable death.’22 Despite the continuation of earlier attitudes, there was an evident medicalization of old age and a growing specialization amongst medical practitioners in geriatric medicine. In nineteenth-century Germany, ideas on ageing were characterized by vitalism (the ‘natural ebbing of lifeforce’), which put the medical study of old age into a general framework of knowledge about the life course that contrasted to old Galenic models, which still lingered in some other parts of Western Europe.23 Elsewhere, doctors and writers paid more attention to the different stages of old age and began to generate a binary model of the medical needs of the aged. Thus, medical dictionaries and textbooks separated ‘normal’ declines (such as osteoporosis) in the ageing process from ‘morbid’ degeneration (such as arterial sclerosis).24 This process of identifying certain aspects of the natural ageing process as diseases had a twofold impact. On the one hand, such a label implied that these aspects of decay might be curable; on the other, this method of treating the natural symptoms of old age as a sickness reinforced the tendency to shift old age care into medical care. Not surprisingly, then, the later nineteenth century witnessed physicians in the United Kingdom and France, in particular, directing the medical profession’s new-found confidence and methods towards the treatment of the aged. Increasingly intrusive methods of intervention were developed in order to make the last stage of life healthier and less burdensome. Still, while twentieth-century physicians came to focus on curing certain of old age’s problems, in the nineteenth century: ‘Fundamentally, in most countries, the field was still constrained by the belief that the elderly were incurable.’25 This pessimism about the health of the elderly was challenged in the twentieth century by one set of doctors and medical writers, even as others continued to hold extremely negative attitudes about the nature of the ageing process. Both sets of thought were part of a new focus by the medical profession on the issue of old age. Indeed, it was in the early twentieth century that we finally find the term ‘geriatrics’ invented, by Ignatz

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Nascher (1863–1945), an Austrian who emigrated to the United States and participated in a general trend of doctors recognizing that there was a need for specialization in geriatrics from the turn of the century. In distinguishing between geriatrics and gerontology, Nascher emphasized that ‘disease in old age . . . is . . . a pathological process in a normally degenerating body.’26 According to Nascher, there was a need to treat the diseases of elderly people not as part of old age, but as curable illnesses. He was also an advocate for mental stimulation, proper diet, and activity. Along with Nascher, we see a general shift in location, to the United States, for advances in medical understanding and treatment of old age in the early twentieth century. From the 1920s, a first wave of articles emerged by doctors who sought to address old people more generally on their health care. Innovations during those decades included not only new theories about physical health, but also breakthroughs in the understanding of mental wellness in old age. For example, Alois Alzheimer (1834–1915) helped to refine understanding of senile brain diseases and Lillien J. Martin’s Salvaging Old Age (1930) recognized the particular problems of stress in later life. British innovations in geriatric care from the 1930s centred on physical therapy for the elderly, following Marjorie Warren’s initiatives at Middlesex Hospital, where her new techniques in physical rehabilitation caught the attention of colleagues and ushered in a new era of more positive approaches to mobility in later life.27 These concerns intensified in the 1930s and 1940s, thanks to an increased international concern with demographic change. A new awareness of declining birth rates and increased life expectancy in most Western European nations prompted a surge of interest in gerontology and geriatrics. From the first decades of the twentieth century, we can find evidence of new levels of interest and new professionalization in the medical attention and specialization regarding the health of the elderly. In 1917, medical journals began to add sections on geriatrics, while by the 1940s and 1950s, there were medical journals devoted to geriatrics in Germany, Italy, and France. E. V. Cowdry (1888–1975) edited a seminal collection of essays by prominent medical figures, entitled the Problems of Aging, in 1937, which helped to enhance the prestige, as well as the goals, of geriatric medicine in the United States. Similarly, the British Society for Research on Ageing was founded in 1939, while the USSR hosted the first international gerontology conference in 1938.28 This interest and research resulted in some real benefits for the elderly by the later twentieth century, with innovations such as heart bypass surgery and hip and knee replacements becoming commonplace by the end of the century.29 By the later twentieth century, of course, geriatrics had become well established and it is currently a growing and vibrant field. Moreover, recent decades have witnessed a renewed focus on quality of life, rather than just palliative care. Physicians specializing in geriatrics, as well as care providers from other arenas, now include specialists in the particular needs of the elderly in regards to hearing and seeing, dentistry and podiatry. Such an array of interests reflects the current consensus on disease in old age, which highlights the complex and overlapping ways in which diseases and chronic health decline combine in the elderly, thereby rendering impossible a single solution to any given older person’s medical problems.30

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Menopause While medical writers throughout the pre-modern era focused almost exclusively on male ageing, there were a few medical texts written specifically on female ageing, and these focused primarily on menopause. It is surprising that more was not written regarding women’s experiences of ageing since one of the great constants in the medical history of old age is the greater female longevity that has been evident in nearly all times and regions since the Middle Ages. Much more was written about women’s particular experience of the ageing process, and their needs, after the early twentieth century. Indeed, some feminist historians have argued that the invasive care for female reproductive health (including during menopause) that became more frequent in the modern age was damaging for women.31 De Secretis Mulierum was an early text used in the Middle Ages and was typical of one genre, which saw the cessation of the menses as detrimental, since the woman’s body could no longer purge itself of the impurity of menstrual fluid. By this way of reckoning, then, the post-menopausal woman was herself venomous, especially if she had lived on a poor diet.32 Other early modern and medieval authors, following Hippocrates’ view that ‘menopause signalled the re-assimilation of the female body to the male’, viewed women after menopause as more masculine, which was both a positive change and one that threatened gender instability.33 There was an assumption, in many works, that men’s and women’s health were fundamentally different and much ink was spilled on the subject of women’s reproductive health in particular. A particularly interesting eighteenth-century text was ‘Remarks on the Final Cessation of the Menses’, which was really a quack advertisement under the guise of medical literature. This text embodies what Michael Stolberg has identified as the ‘irritation’ model of menopause typical of the later eighteenth and early nineteenth centuries. The ‘Remarks’ highlighted the dangers of menopause, and ‘pathologized’ this period as one that brought women to the brink of physical destruction. At the same time, the text shows that women who survived the climacteric could be stronger, healthier, and more mentally acute than ever. The Enlightenment era thus witnessed an exacerbation of both the tendency to pathologize and to valorize menopause in women, both trends having been apparent in earlier periods.34 Nineteenth-century medicine continued to devote little time to women’s ageing, still ignoring menopause and still not explaining women’s greater longevity, though at least now the latter was noticed. Finally, in the early twentieth century, menopause featured more prominently in medical literature and discussions. As medical explanations focused more on the role of glands in the ageing process, the hormonal changes associated with menopause became of more interest and new ideas and therapies were gradually discussed with a special relevance to menopause. However it was understood, menopause was generally expected to take place at some point between the ages of fortyfive and fifty-five, with ages clustering around fifty, throughout Western European

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history, which marks it as a point of some continuity in the medical history of ageing. Of course, the experience of menopause would have differed according to circumstances. As several historians have noted, the diet of the poor would have made women more susceptible to osteoporosis and other diseases, while in certain eras, wealthy women also avoided dairy products, unwittingly subjecting themselves as well to the increased likelihood of humped and bent spines and tooth loss.35

Prolongevity An important truth of gerontology has been succinctly expressed by J. L. Alvorn: ‘The central problem of geriatric medicine “is that human beings are in fact mortal, we must die of some terminal event”. It remains as it has been throughout its history, uncertain about how this event is to be approached or managed.’36 Ironically, then, one of the most interesting aspects of the study of old age has been the history of ideas about prolonging life, the effort to delay death, perhaps indefinitely. Studies in this field have been generally characterized by a subtle approach and an accessible style, differing not in the story told, but in the scope and methods of relating the often amusing history of humanity’s search for immortality.37 Ideals about how to counter the symptoms and discomfort of old age, and to actually extend the life course, were a consistent preoccupation from the classical and biblical worlds into the modern day. Galen labelled the special medical issues related to old age as ‘the gerocomic art’ and focused on the need to warm and moisten the ageing body as a way to counter humoral imbalance. While many classical writers (such as Seneca) classified old age as a disease, Galen disagreed, classing old age as an intermediate but natural state between health and disease.38 From Galen’s On the Preservation of Health through modern self-help volumes, nearly all works that sought to promote longevity focused on the need for moderate diet and exercise. At the same time, however, medical texts through the ages associated old age with a tendency towards specific diseases and ailments, especially respiratory and circulatory illness. In the face of such diseases and discomforts, medical practitioners and writers generally focused on amelioration and prevention, not cure, because such ailments were seen to be an inevitable feature of the ageing process. Even spiritual works offered some hope not only for prolonging life, but also for human agency in determining a positive and beneficial ageing process.39 The Italian Renaissance author Alvise Cornaro (1484–1566) offered a personalized and optimistic view of the possibility of extending a healthy and enjoyable age through a moderate diet and exercise, but he, like many, emphasized the importance of a stable mental and social state. Indeed, religious, humanistic, and medical texts show complex interactions, as Daniel Schäfer has demonstrated: cultural conceptions of the physiology of ageing were formed by the exchange of ideas, metaphors, and ‘scientific’ theories within a wide range of genres and disciplines.40

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Because of Enlightenment optimism about the potential for human well-being, texts that focused on the prolongation of life were particularly prevalent and optimistic in the eighteenth century. The Essay on the Most Rational Means of Preserving Health (1799), for example, ended with a list of dozens of cases of longevity throughout history and, although many of these were contested in the next century by William Thoms’s Human Longevity: Its Facts and Fictions (1873), many texts continued to celebrate individual achievements of longevity from the eighteenth century to the present. There was still, however, tremendous continuity with the classical and Renaissance texts devoted to this topic. The essential recipe for maintaining health in old age remained: eat moderately, exercise consistently, and be of a cheerful, even temper. Such texts were, by the eighteenth century, generally written for a wide audience, for those ‘unaccustom’d to think and reason on medicinal Subjects’.41 The optimistic tone of texts on prolonging life is striking, from Ponce de Leon’s accounts of his search for the Fountain of Youth in the late-fifteenth-century Spanish empire, through John Hill’s (1714–75) belief that disease in old age is easy to prevent, to Elie Metchnikoff ’s (1845–1916) faith in medicine’s ability to cure most causes of senescence. The texts are most often realistic and pragmatic in describing the declining abilities of the old, but their belief in the ability to mitigate discomfort in old age is part and parcel of their desire to cast this stage of life in less hopeless terms than was the case in traditional medical literature. Old men and women were expected, in these texts, to carefully monitor and assist their own good health. In the end, such texts give a sense of the empowerment of older men and women, putting the burden of their condition on their own shoulders. Alongside scientific works on preserving health into old age, essays and broadsides of more dubious worth were published in ever greater numbers with the rise of both the periodical press and advertising. These reached an early peak in the eighteenth century, and by the twentieth, of course, they had achieved a point of absurdity. There were both mock-medical texts and ballads openly scorning the search for cures to ageing, alongside commercial advertisements and popular medical guides. William Brodum’s (1767–1824) A Guide to Old Age, for instance, was really an extended sales-pitch for his ‘nervous cordial’ and ‘botanical syrup’. Brodum’s work also featured a tirade against ‘self-pollution’, which reveals not only a traditional disgust of masturbation, but also an attention to a ‘spermatic economy’, which some scholars have linked to gerontocratic notions in the Victorian era.42 For the past several centuries it has been hard to distinguish between ‘legitimate’ medical texts of prolongevity and mere quackery, as throughout the nineteenth and twentieth centuries new innovations in prolonging life and health in old age ranged from the mundane to the bizarre. On one hand, there is an extremely practical vein that travels through the history of this literature. From Aristotle, Galen, Luigi Cornaro, Bacon, the Marquis de Condorcet, Darwin, Freud, and into the present, all of these writers recognized what Galen called the ‘non-naturals’, explaining how air, diet, sleep, exercise, the elimination of bodily waste, and mental health influenced the length and happiness of life.

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Yet other works, including many from the modern era, contain ‘remedies’ for ageing that hearken back to the magical elixirs of Paracelsus, rather than looking forward to what we currently see as the state of the art in geriatrics. Paracelsus’s sixteenthcentury remedies included antimony, sulphur, gold, and opium, which were to be taken until one’s nails and hair fell out. Knowledge of germs and improved surgical techniques transformed early-twentieth-century medical views of the human body and greatly enhanced the possibilities for intervening against disease and senescence, but rather than leading to a single equation for life extension, a plethora of theories was articulated by the 1930s. These were adopted by disparate groups (eugenicists, psychoanalysts, sexologists, and so on) who shared the intellectual obsessions of the day. Blood, minerals, ground guinea pig reproductive organs, as well as herbs, foods and calorie restriction, all have been seen at various times as miraculous cures for senescence.43 There is a variety of ways to think abut this genre of writings on the prolongation of life. On the one hand, there is a real continuity over the millennia within these texts, as noted above and as is obvious from their bare existence throughout the ages. On the other hand, one can also note the ways in which such works reflect the medical knowledge and social preoccupations of the particular cultures that produced them. While the hope for eternal youth is eternal, the methods for achieving it map onto the medical expertise and mentalities of each era.

Conclusion: new directions The field of the history of old age is both relatively new and relatively uncontentious, with a tendency to grow through the production of collected volumes and an unfortunate dearth of substantial monographs.44 Interest has most often centred on issues related to social welfare and historical demography, although there has been some variation along the general theme of changing attitudes towards old age in cultural history. Still, much of the most fertile and exciting work on the history of old age continues to relate to disagreements over the social and economic determinants of support of older people by families and states in a transnational perspective.45 Although most studies of the history of ageing, and certainly those most relevant to the history of medicine, have focused on the demographic and social history of old age, a few larger works have framed the discussion of old age history more generally as centred on the question of continuity versus change in the historical expectations and experiences of old age. George Minois and Peter Laslett, both pioneers in the field, approached this question very differently. Laslett’s work, while acknowledging major shifts in such features as retirement expectations, generally emphasized continuity over change, as he sought to challenge the myth of a golden age of family history in the past, where the elderly were respected and cohabitation was the norm.46 Keith Thomas, similarly, in a seminal article on ‘Age and Authority’ pointed out early on that the pre-modern era was

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far from gerontocratic in its norms.47 In contrast, George Minois believes that ‘Western history from antiquity to the Renaissance is marked by fluctuations in the social and political role of the old . . . The general tendency however is towards degradation.’48 Recent collections of essays that assess the cultural history of old age over the long term have tended to call into question the notion of any simple trajectory, emphasizing instead the coexistence of positive and ageist norms and variations in the lives of the elderly across time and space.49 Three other, more specific sets of questions currently preoccupy historians in this field. Much interest is attached to studies of changing demographics, especially the problems of population ageing and the related issue of whether ageing is a ‘social problem’.50 Views of the elderly as societal problems contrast with the work of those who focus, instead, on the question of what can lead to successful ageing. In this second arena, the studies tend to be contemporary, but this set of questions (essentially concerned with the promotion of longevity) informs most historical studies of old age as well, and, of course, shapes in many ways medical discourses regarding old age.51 Finally, and unsurprisingly in a world that finds itself facing crises in pension schemes and social insurance, there is currently a burgeoning literature on pensions and on old age institutions.52 Although the historiography of old age has been diverse, and even fragmented, characterized more by micro-studies than by synthesis, there are also attempts to pull together recent developments and to summarize our knowledge of old age.53 Such works help historians of old age, as well as medical historians interested in geriatrics, to frame their work within the overarching structures of demographic changes and cultural continuities in the field.

Notes 1. Jacob Isaac, ‘Religion alone the cause of happiness in old age. A discourse delivered at the funeral of Mrs. Elizabeth French’, Moreton-Hampstead, 6 February 1787 (Exeter: R. Trewman, 1787), in Oxford University, Harris Manchester College, T 211.15. My thanks to the librarians at Harris Manchester for supplying me with a copy. 2. BL Add. MS 22225, fol. 495r–496r. Novbr ye 24 [1726]. Thanks to Ingrid Tague for this reference. 3. N. MacKenzie and J. MacKenzie, The Diaries of Beatrice Webb, Vol. 4 (London, 1986), cited in P. Thane, ‘Old Women in Twentieth-Century Britain’, in L. Botelho and P. Thane (eds), Women and Ageing in Britain since 1500 (Harlow: Longman, 2001), 218–19. 4. E. A. Wrigley and R.S. Schofield, The Population History of England (Cambridge: Cambridge University Press, 1981); Wrigley et al., English Population History from Family Reconstitution, 1580–1837 (New York: Cambridge University Press, 1997); J. Dupâquier, Pour la Démographie Historique (Paris: Presses universitaires de France, 1984); D. Haycock, Mortal Coil: A Short History of Living Longer (New Haven, CT: Yale University Press, 2008). 5. T. Parkin, ‘The Ancient Greek and Roman Worlds’, in P. Thane (ed.), The Long History of Old Age (London: Thames and Hudson, 2005), 37.

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6. Ibid. 40. 7. Shulamith Shahar, ‘Who Were Old in the Middle Ages?’, Social History of Medicine, 6 (3) (December 1993), 313–41; idem, Growing Old in the Middle Ages: Winter Clothes Us in Shadow and Pain (London: Routledge, 1997); Joel Rosenthal, Old Age in Late Medieval England (Philadelphia: University of Pennsylvania Press, 1996), 96–8. 8. L. Botelho, ‘Old Age and Menopause in Rural Women of Early Modern Suffolk’, in Botelho and Thane (eds), Women and Ageing in Britain since 1500, 43–65; S. Ottaway, The Decline of Life: Old Age in Eighteenth-Century England (Cambridge: Cambridge University Press, 2004), 1–64. 9. Parkin, ‘The Ancient Greek and Roman World’, 41; Shulamith Shahar, ‘The Middle Ages and Renaissance’, in Thane (ed.), The Long History, 71, 79; Botelho, ‘Old Age and Menopause’; Shahar, ‘The Middle Ages’, 79; M. Mitterauer and R. Sieder, The European Family: Patriarchy to Partnership from the Middle Ages to the Present , trans. Karla Oosterveen and Manfred Hörzinger (Chicago: University of Chicago Press, 1983), 146; L. Botelho, ‘The Seventeenth Century’, in Thane (ed.), The Long History, 113–73, 148. 10. W. A. Achenbaum, Old Age in the New Land: The American Experience since 1790 (Baltimore: Johns Hopkins University Press, 1978), 60; D. Troyansky, Old Age in the Old Regime: Image and Experience in Eighteenth-Century France (Ithaca, NY: Cornell University Press, 1989), 9; R. M. Smith, ‘The Structured Dependence of the Elderly as a Recent Phenomenon: Some Sceptical Historical Thoughts’, Ageing and Society, 4 (1984), 414—all cited in Thomas R. Cole and Claudia Edwards, ‘The 19th Century’, in Thane (ed.), The Long History, 220. 11. P. S. Nyce and S. Schieber, The Economic Implications of Aging Societies: The Costs of Living Happily Ever After (New York: Cambridge University Press, 2005), 15. 12. P. Thane, ‘Old Age’, in R. Cooter and J. Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000), 617–32, at 618. 13. Parkin, ‘The Ancient Greek and Roman World’, 59–60. 14. Shahar, ‘The Middle Ages,’ 83, citing Roger Bacon, Opus majus, ed. J. Bridge (Frankfurt, 1964), II: 206. 15. L. Botelho, ‘Introduction’, in L. Botelho and S. Ottaway (eds), History of Old Age, 1600–1800, 8 vols (London: Pickering and Chatto, 2008), I, xlix–xlx. 16. P. Ker, ‘Meditation IV. Of Old Age’ in The Map of Man’s Misery, in Botelho and Ottaway (eds), History of Old Age, I, 188. 17. D. Schäfer, ‘ “That Senescence Itself is an Illness”: A Transitional Medical Concept of Age and Ageing in the Eighteenth Century’, Medical History, 46 (2002), 525–48. 18. Nicholas Robinson, A New Method of Treating Consumptions (London: A. Bettesworth et al., 1727), xii–xiii. Reprinted in Botelho and Ottaway (eds), History of Old Age, II, 111–18. For further discussion of consumptions, see in this volume Chapter 22 by Carsten Timmermann. 19. P. Thane, ‘Geriatrics’, in W. F. Bynum and R. Porter (eds), Companion Encyclopedia of the History of Medicine, 2 vols (London: Routledge, 1993), II, 1092–1115, at 1100, 1102. 20. P. Stearns, Old Age in European Society: The Case of France (New York: Holmes and Meier, 1976), 83–97; C. Conrad, ‘Old Age and the Health Care System in the Nineteenth and Twentieth Centuries’, in P. Johnson and P. Thane (eds), Old Age from Antiquity to PostModernity (London: Routledge, 1998), 132–45.

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21. Thane, ‘Old Age’, 620; J. Dupâquier (ed.), Histoire de la population française, tome 3—De 1789 a 1914 (Paris: Presses universitaires de France, 1988), 555. 22. Cole and Edwards, ‘The 19th Century’, 244. 23. Hans-Joachim von Kondratowitz, ‘The Medicalization of Old Age: Continuity and Change in Germany from the Late Eighteenth to the Early Twentieth Century’, in M. Pelling and R. M. Smith (eds), Life, Death and the Elderly: Historical Perspectives (London: Routledge, 1991), 134–64; Thane, ‘Geriatrics’, 1101. 24. Cole and Edwards, ‘The 19th Century’, 244. 25. Thane, ‘Geriatrics’, 1102. 26. J. T. Freeman, ‘Nascher: Excerpts from His Life, Letters and Works’, Gerontologist, 1 (1961), 17–26, cited in Thane, ‘Geriatrics’, 1103–4. 27. Thane, ‘Geriatrics’, 1105–7; T. Cole, The Journey of Life (Cambridge: Cambridge University Press, 1992). 28. W. A. Achenbaum, Crossing Frontiers: Gerontology Emerges as a Science (Cambridge: Cambridge University Press, 1995), 64–5, 98–9; Thane, ‘Geriatrics’, 1104–07. 29. Thane, ‘Old Age’, 630. 30. Achenbaum, Crossing Frontiers, 251–68. 31. Germaine Greer, The Change: Women, Ageing, and the Menopause (New York: Knopf, 1991); Lois Banner, In Full Flower: Aging Women, Power and Sexuality (New York: Knopf, 1992). 32. Shahar, ‘The Middle Ages’, 84, citing De Secretis Mulierum, cited in D. Jacquart and C. Thomassert, Sexuality and Medicine in the Middle Ages, trans. M. Adamson (Oxford: Oxford University Press, 1988), 75. 33. L. A. Dean-Jones, Women’s Bodies in Classical Greek Science (Oxford: Oxford University Press, 1994), 107, cited in Botelho, ‘Old Age and Menopause’, 52; S. Mendelson and P. Crawford, Women in Early Modern England (Oxford: Oxford University Press, 1998), 23, 184–5. 34. Michael Stolberg, ‘A Woman’s Hell? Medical Perceptions of Menopause in Preindustrial Europe’, Bulletin of the History of Medicine 73(3) (1999), 404–28; Mendelsson and Crawford, Women in Early Modern England, 126. 35. D. W. Amundsen and C.J. Dyers, ‘The Age of Menarche in Medieval Europe’, Human Biology, 45 (1973), 363–9; J. B. Post, ‘Ages of Menarche and Menopause: Some Medieval Authorities’, Population Studies, 25 (1971), 83–7; Botelho, ‘Old Age and Menopause’, 43–65. 36. Thane, ‘Geriatrics’, 1112, citing J. L. Avorn, ‘Medicine: The Life and Death of Oliver Shay’, in A. Pifer and L Bronte (eds), Our Aging Society (New York: Norton, 1986), 295 n 46. 37. G. Gruman, A History of Ideas about the Prolongation of Life: The Evolution of Prolongevity Hypotheses to 1800, Transactions of the American Philosophical Society, ns, 56 (9) (Philadelphia: American Philosophical Society, 1966); Haycock, Mortal Coil. 38. Parkin, ‘The Ancient Greek and Roman’, 60; Schäfer, ‘ “That Senescence Itself is an Illness’”. 39. Shahar, ‘The Middle Ages’, 90. 40. D. Schäfer, ‘Medical Representations of Old Age in the Renaissance’, in Erin Campbell (ed.), Growing Old in Early Modern Europe: Cultural Representations (Aldershot: Ashgate, 2006), 11–19. 41. An Essay on the Most Rational Means of Preserving Health, and Attaining to an Advanced Age. To Which Are Added Anecdotes of Longevity (London: James Wallis, 1799), reprinted in Botelho and Ottaway (eds), History of Old Age, II, 186–96; R. Porter and D. Porter

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42.

43. 44. 45.

46.

47. 48. 49. 50.

51. 52.

53.

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(eds), In Sickness and in Health: The British Experience, 1650–1850 (London: Fourth Estate, 1988), 30–1. W. Brodum, A Guide to Old Age, or a Cure for the Indiscretions of Youth, 46th edn (London: J. W. Myers, 1799); M. M. Gullette, ‘Male Midlife Sexuality in a Gerontocratic Economy: The Privileged Stage of the Long Midlife in Nineteenth-Century Age-Ideology’, Journal of the History of Sexuality, 5 (1) (1994), 58–89. Haycock, Mortal Coil, passim. S. Ottaway, ‘Introduction’, to S. Ottaway, L. Botelho, and K. Kittredge (eds), Power and Poverty: Old Age in the Pre-Industrial Past (Greenwich, CT: Greenwood, 2002), 1–12. P. Teo, et al., Ageing in Singapore: Service Needs and the State (London: Routledge, 2006); I. Aboderin, Intergenerational Support and Old Age in Africa (New Brunswick, NJ: Transaction, 2006). P. Laslett, ‘The History of Ageing and the Aged’, in Family Life and Illicit Love in Earlier Generations (Cambridge: Cambridge University Press, 1977), 174–213; P. Laslett and R. Wall, Household and Family in Past Time (Cambridge: Cambridge University Press, 1972); D. Kertzer and P. Laslett, Aging in the Past: Demography, Society and Old Age (Berkeley: University of California Press, 1995). Keith Thomas, ‘Age and Authority in Early Modern England’, Proceedings of the British Academy, 62 (1976), 207. G. Minois, History of Old Age: From Antiquity to the Renaissance, trans. Sarah Hamburg Tenison (Chicago: University of Chicago Press, 1987), 7. Campbell, Growing Old in Early Modern Europe; Thane (ed.), The Long History; Kertzer and Laslett, Aging in the Past. J. Boston and J. A. Davey, Implications of Population Ageing: Opportunities and Risks (Wellington, New Zealand: Institute of Policy Studies, School of Government, Victoria University of Wellington, 2006); H. Yoon and J. Hendricks, Handbook of Asian Aging (New York: Baywood, 2006); R. Dhar Cakraborti, The Greying of India: Population Ageing in the Context of Asia (New Delhi: Sage, 2004); E. M. Gee and G. M. Gutman, The Overselling of Population Aging: Apocalyptic Demography, Intergenerational Challenges and Social Policy (New York: Oxford University Press, 2000); S. Harper, Ageing Societies: Myths, Challenges and Opportunities (London: Hodder Arnold, 2006). M. Bernard and T. Scharf, Critical Perspectives in Ageing Societies (Bristol: Policy Press, 2007). E. M. Immergut, K. M. Anderson, and I. Schulze, The Handbook of West European Pension Politics (New York: Oxford University Press, 2007); R. Blackburn, Banking on Death—Or, Investing in Life: The History and Future of Pensions (London: Verso, 2002); G. C. Cook, The Incurables Movement: An Illustrated History of the British Home (Oxford: Radcliffe, 2006). M. L. Johnson (ed.), The Cambridge Handbook of Age and Ageing (Cambridge: Cambridge University Press, 2005).

Select Bibliography Achenbaum, W. A., Crossing Frontiers: Gerontology Emerges as a Science (Cambridge: Cambridge University Press, 1995). Botelho, Lynn, and Pat Thane (eds), Women and Ageing in British Society (London: Longman, 2001).

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Cole, Thomas, The Journey of Life: A Cultural History of Aging in America (Cambridge: Cambridge University Press, 1992). Haycock, David, Mortal Coil: A Short History of Living Longer (New Haven, CT: Yale University Press, 2008). Johnson, Paul, and Pat Thane (eds), Old Age from Antiquity to Post-Modernity (London: Routledge, 1998). Ottaway, Susannah, The Decline of Life: Old Age in Eighteenth-Century England (Cambridge: Cambridge University Press, 2004). Pelling, M., and R. M. Smith (eds), Life, Death and the Elderly: Historical Perspectives (London: Routledge, 1991). Shahar, Shulamith, Growing Old in the Middle Ages: Winter Clothes Us in Shadow and Pain (London: Routledge, 1997). Thane, Pat, Old Age in English History: Past Experiences, Present Issues (New York: Oxford University Press, 2000). —— (ed.), The Long History of Old Age (London: Thames and Hudson, 2005). Troyansky, David, Old Age in the Old Regime: Image and Experience in Eighteenth-Century France (Ithaca, NY: Cornell University Press, 1989).

chapter 20

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Since the 1970s, historians have increasingly fused demographic studies with interest in social and cultural attitudes towards death and dying, examining the key actors in death scenarios, probing the material culture surrounding death, disposal, and mourning and, more recently, exploring histories of emotion in relation to dying and bereavement. The turn to attitudes and affect has not excluded the history of medicine but, rather, sought to demonstrate the complex relationship between social and professional organizations, individuals and families. Notably, historians have pointed to death as a site where competing narratives of secularism and science, rationality and spirituality, the private and the public are contested. The history of death has, to a point, been situated in relation to these competing narratives to suggest a linear chronology whereby a sacred and community-centred culture eventually gave way to a privatized and sanitized culture of death. This chapter explores the legitimacy of this chronology and its implications for understanding attitudes to death in the past. In Western modernity, death is usually defined as the cessation of vital functions. Grounded in the realm of the biological, this definition is confirmed by medical certification and the legal registration of death. Other physiological signs indicate that death has occurred (changes to the eyes, which become fixed with slightly enlarged pupils; the relaxation of jaw, bladder, and rectal muscles; the cooling of body temperature; and modification of skin tone), while death’s ‘rattle’ in the throat, loss of consciousness, and disinterest in foods or fluids can intimate death’s approach. Yet definitions of biological death are far from fixed and rarely removed from the cultural context in which death takes place. In the nineteenth century, debates concerning the morality of poorer parents and infant mortality highlighted elastic conceptions of birth and death in relation to newborns, with some practitioners and midwives classifying babies who had lived for several days and even been christened as stillborn. The failure of vital organs may be intrinsic to contemporary conceptions of death but the meanings attributed to death’s signifiers and confidence in death’s experts are not constant. The apparent finality of biological death in medieval cultures was complicated by examples of ‘miraculous’ resurrection, indicating the influence of religion in shaping understandings of life and death.

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In late Victorian culture, belief in resurrection had been eclipsed by anxieties about premature burial and the medical profession’s ability to correctly identify and interpret biological signs of death. More recently, definitions of death have been complicated by calls for the medical profession to address the ethical consequences of distinctions between physical and cerebral death and recognize the emotion invested by families and friends of the brain dead in life support machines that keep a body physically alive. If definitions of biological death are not always stable, the processes by which death is made public are even more fluid. The medical and legal procedures for identifying the dead in contemporary society are organized to ensure that causes of death are clearly registered, that people are properly dead and their remains treated in an appropriate manner. However, the declaration of death is also managed via other agencies and social forms, such as newspaper announcements, telephone calls, funerals, letters, and conversations. As Lindsay Prior notes, death is not simply an event, suspended in a moment of biological time but, rather, a process of social organization.1 Similarly, some conceptions of death are sufficiently elastic to precede biological collapse, for instance, in the isolation and withdrawal of certain groups, such as the terminally sick or the elderly, from a social world. Likewise, as Pat Jalland’s work on elite Evangelical families in Victorian Britain depicted, death can be understood as a spiritual journey that begins in diagnosis of terminal disease and reaches its end-point in expiration.2 The interplay of biological, cerebral, and cultural definitions of death is pivotal to historical approaches to death. Chronologies of cultural attitudes towards death have been shaped overwhelmingly by an assumption that a spiritual-centred definition of death, prevalent in the medieval Christian world, gave way by the modern period to a medicine-centred conception. Interpretations of this shift are often made in relation to conceptions of what constituted a ‘good’ death, a concept that implies a broad evaluative framework for negotiating the meaning and impact of death. Historians have tended to identify a Christian narrative, whereby good death depended on making spiritual preparation for one’s demise, as antithetical to a medical discourse that, from the late nineteenth century, increasingly deemed death to be a professional failure. This chapter will first assess the usefulness of shifting notions of ‘good death’ before discussing why histories of death have pitched science and religion in opposition.

Good death Death as a biological event is tied to economic, social, and cultural contexts that render the meanings invested in death as broadly situational. The most tenacious extra-biological definition of death rests upon the notion of dying well. Historians of most chronological periods, and certainly since the early Middle Ages, have identified shared understandings of ‘good’ death and, within elite culture at least, a language on the ‘art’ of dying (ars morendi) that was often tied to a didactic religious culture. Dominant understandings of good death hinged, certainly until the Victorian period, upon a desire to

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save one’s soul but, also, to place financial and domestic affairs in order. This is not to suggest that good deaths are ahistorical but, rather, that most historians identify elite notions of how to die well in different chronological periods. The Christian narrative of good death privileged seeking forgiveness for sins and preparing to meet God the redeemer and the judge. In Catholic cultures, the presence of a cleric at the deathbed to administer last rites and extreme unction to the dying were highly desirable for securing the soul’s smooth journey through purgatory, although a communal culture of praying for the deceased cemented this or, at least, compensated for it if death was speedier than the priest. The well-to-do held an advantage in securing a good death, not least because they could pay for masses and for ‘doles’ to induce numbers of the poor to pray for the soul of the dead. In Protestant doctrine, the dying individual bore sole responsibility for their soul and the final judgement moved to the moment of death to enhance the importance of preparing for death, both in terms of living according to God’s purpose and in reaffirming faith in God’s will through the expression of contrition and humility as death approached. This spawned a vast amount of didactic literature but, in practice, prayers for the dead continued long after the Reformation. When Father Dolling, an Anglican priest in late Victorian Portsmouth, was removed from office for saying prayers for the souls of the deceased, his defence rested on the claim that he was responding to working-class parishioners’ desire for emotional consolation through action.3 This example also suggests that the relevance of elite conceptions of good death to poorer groups in society is questionable. To suggest that economic insecurity cancelled the physical, emotional, or spiritual fear of death is naїve. Nonetheless, the preparation for demise required by most understandings of good death was inevitably shaped by access to material and spiritual resources and it is not inconceivable that loss of work, poor living conditions, and the expense of illness and death made quick deaths desirable for the labouring poor. By the Victorian period an expansion in consumer markets, rising literacy levels, cheap print culture, and a medley of multi-denominational charities ensured that conceptions of the good death were at least disseminated broadly. Although didactic proselytizing, from theological tracts through to popular fiction, located religion as pivotal to dying well, ideals of good death also served a psychological function, especially in relation to the deaths of children and infants. Children’s literature extolled the virtues of dying in Jesus, both as a means for preparing children for the possibility of death and as a cultural framework for grieving parents and siblings to achieve reconciliation and restitution to bereavement of the young. The vulnerability of children across the social scale to infectious diseases such as typhus, scarlet fever, or smallpox rendered parents and siblings helpless in the face of potential multiple deaths as illness spread from one child to another. Narratives of death that privileged the love of Christ above the temporal ties of family and friendship provided a framework in which to explain untimely deaths and to recast death from the realm of tragedy to one of hope and reunion. The Archbishop of Canterbury and his wife lost five of their children to scarlet fever in 1856. Emotionally overwrought by their loss, they finally found consolation and restitution from their Evangelical beliefs in God’s purpose.4 Narratives of the good death privileged

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submission to God’s will but also provided a rationale for death. Mary Sewell’s sentimental Ballads for children (1868) suggested that good death was egalitarian: little ragged children could trip as happily into the bosom of heaven as pampered darlings, and God acted in wisdom and love when he called home children that were too delicate for the temporal world. Although ideals of good death held psychological benefits, they also created multiple anxieties about dying badly. Since early medieval times, conceptions of bad death rested upon lack of preparation for expiration or renunciation of God, the collapse or absence of a rationale for death, and deaths that ruptured social rituals for disposing of the dead.5 As anthropologists note, communal death rites enable the dying and bereaved to pass successfully through the liminal period after expiration whereby the deceased is incorporated into the world of the dead and the bereaved are returned to the world of the living. The removal of such rites ruptures that process.6 For instance, in France, excommunication from the Roman Catholic Church and prohibition of burial rites cast shame and dishonour on the dead and implied that prayers for their soul were futile. Of equal significance, however, excommunication removed customs that were commonly used to establish an individual’s place within a community and secure catharsis for the bereaved.7 Until at least the nineteenth century, suicide was considered the worst death because the Church considered taking one’s own life a grievous sin while social, legal, and religious sanctions meant that death customs and inheritance rights were forfeited. While some historians have suggested that suicide in Britain became secularized by the beginning of the nineteenth century, this is contested given the Evangelical and moral conservatism of the Victorian period.8 Moreover, while individual clerics and coroners exercised discretionary leniency in dealing with suspected suicides, financial penalties from life insurance companies persisted and suicide remained a crime in Britain until 1961. Violent and sudden deaths also breached notions of good death because such fatalities were often deemed untimely and/or unjust and because injuries to, or the absence of, the deceased curtailed customs such as washing and viewing the corpse. The sheer scale of popular participation in ceremonies that recognized and remembered the fallen during the Great War demonstrates, among other things, the extent to which shared rites of passage surrounding death are pivotal to notions of community, compassion, and closure. While perpetuating its use as a historical category, most historians acknowledge that good death is a problematic tool. While good deaths represented an ideal, in an experiential context, the dying and bereaved have adopted a selective and fluid understanding of good death that has often been renegotiated over time. If the good death was only ever an aspiration, however, its usefulness for exploring attitudes at the deathbed is called into question. Recently, Alan Kellehear has suggested that historians of death need to free themselves from the religious and cultural baggage of good and bad death narratives to focus instead on a concept of ‘managing’ death that accommodates the kaleidoscope of experiences and emotions with which individuals approach dying. As Kellehear notes, notions of managing death permit a contextual approach to studying death in the past and can be utilized, as Kellehear’s work demonstrates, across

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swathes of time, geography, and culture.9 Notions of good death have also limited the questions historians have asked about death in the past. Notably, a preoccupation with the art of dying is overwhelmingly located in articulate, elite cultures that bequeath a historical record of feelings, beliefs, and aspirations and which relate ready access to the professions of death: clerics, lawyers, doctors, and, latterly, funeral directors. Likewise, narratives of good death tend to suppose that cultures of death grounded in the realm of the sacred were supplanted, increasingly from the late seventeenth and eighteenth centuries, by the profane. In this account of changing attitudes, the significance of God at the deathbed is superseded by the rising deity of the medical practitioner who, increasingly, had little truck with notions of good death at all.

Secularism, sanitation, and science In his seminal study of Western attitudes towards death from the twelfth century to the twentieth, Phillipe Ariès (1981) portrayed shifting attitudes within the context of competing narratives of theology, science, community, and individualism. Inevitably, doctrinal change shaped social practices surrounding death, although this was often piecemeal and generated unexpected outcomes. For example, ghosts were often explained in post-Reformation culture in the context of lost souls who, in the absence of prayers for the dead, were caught between this world and the next.10 The Enlightenment sought to explain death in rational terms of biological change, but the potential to divest death of spectacular or abstract resonance was stalled by Romanticism and an expanding commercial market for mourning paraphernalia that transformed death into a dazzling display of sentiment and status. This vibrant affective and commercial culture shrank in the face of declining mortality rates from the 1870s, medicine’s expanding expertise in preventative and curative science, secularization, and, finally, the mass bereavement of the Great War. By the middle of the twentieth century, death increasingly took place in the sanitized locus of the hospital; families and clerics were supplanted at the deathbed by medical staff; corpses were no longer cared for by relatives but removed to sterile chapels of rest; sentimental and sacred languages of loss were replaced by anodyne rhymes from the American card company Hallmark. For Ariès, such change was diabolical and lent weight to the social commentator Geoffrey Gorer’s claim in 1955 that the twentieth century witnessed the triumph of a pornographic culture of death: death was sequestered from public view as if it was a dirty secret.11 The flaws within Ariès’s chronology are well documented: generalizations from Catholic France to Protestant cultures; a discrete notion of cultural change; a focus on elite practices as representative of broader attitudes; and the polemical character of his thesis. Nonetheless, his ideas remain influential, not least because the sheer ambition of his chronology has provided a starting point for more period-specific studies and because he sought to move the study of death away from a preoccupation with demography to demonstrate that death had multiple and flexible social and cultural meanings

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that were inextricable from understandings of the afterlife, the emotional culture of loss, material opportunities for the expression of mourning, and the effects of medical intervention in death. Moreover, Ariès’s perception that the twentieth century was an age when death became pathologized and professionalized has met with much less resistance. What remains hotly contested is how far this shift was complete and whether it was entirely negative. Undoubtedly, it is possible to identify shifts in the management of death in the twentieth century. From an individual with a specific history and identity in the nineteenth century, the corpse became an ‘it’: a sanitary problem to be managed by professionals and housed in a sterile environment. Undertaking, or ‘black jobbing’, became professionalized with the formation in Britain of the National Association of Funeral Directors in 1905.12 Even grief became increasingly classified within normative and pathological categories with the publication and subsequent development of Freud’s essay ‘Mourning and Melancholia’ (1917) by psychoanalysts such as John Bowlby (1969), Colin Murray Parkes (1972), and Beverly Raphael (1983). A boom in the second half of the century in bereavement guidance and counselling services potentially implied that the task of consolation had also moved from the realm of the personal to the professional.13 The publication of Elisabeth Kübler-Ross’s influential On Death and Dying (1969) also sought to identify five stages of grief that the dying experienced on learning of their terminal condition. In practice, the stages were non-linear but the sheer idea that responses to dying could be classified into phases appeared to suggest a normative experience against which deviations appeared pathological. While such shifts signalled a change from social and cultural to professional management of death, these were not intrinsically negative. Neither should it be assumed that an increase in the discourses of medicine, sanitation, and hygiene were incompatible with older approaches to death and dying. Accounts of the twentieth century as the era of medicalized and depersonalized death risk viewing science and religion as mutually exclusive institutions that battled for supremacy over the deathbed. For much of the pre-modern period, medicine operated in tandem with religion to prepare the dying for expiration. Highlighting fourteenthcentury guides that helped onlookers determine when death was approaching, Rosemary Horrox notes that lists of symptoms identifying imminent death had a medical purpose but were also inextricable from a moral objective: to enable the dying to make peace with God in good time.14 Medieval conceptions of death as a natural phenomenon did not disappear in the early modern age but advances in vaccination and understanding the causes of disease meant that ‘natural’ perceptions of death were increasingly shaped by science. Ralph Houlbrooke views medicine as making in-roads into religion’s dominance of death by the seventeenth century. Practices such as inoculation and quarantine combined with new drugs (especially quinine and opium) boosted confidence in medicine’s ability to identify, understand, and fight disease. These by no means supplanted Divine meanings attached to death. Rather, the measures that helped to prevent, ameliorate, and limit disease increasingly provided an alternative language for thinking and talking about death and secured, for those who could afford it, the presence at the deathbed of the man of science as well as the man of God.15 Using wills, Ian

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Mortimer suggests that the supremacy of the doctor at the deathbed was established by 1700 when significantly higher numbers of medical men (with or without qualifications) were called to the side of the dying to supplement or facilitate the healing powers of God.16 Similarly, Enlightenment advances in science did not excise God from approaches to death but were intrinsic to perceptions of God as a loving rather than vengeful deity. In any case, as Roy Porter demonstrated, early modern medicine was at least as ineffective as prayer in preventing death.17 Within the Victorian period, Pat Jalland has suggested that an elite Evangelical culture that privileged God’s will clashed with a medical culture that increasingly sought to prevent death and ameliorate distress. Attempts to alleviate pain flew in the face of a religious code that deemed suffering to be a test of faith and demanded lucidity in the face of death in order to receive last rites and bear testimony to faith in God. Yet as Jalland notes, in practice the boundary between religion and medicine was flexible and Christians and doctors tended to work together to ease the pain and anxiety of dying for both the sick and their families. Despite Porter’s assertion that some Georgian practitioners were deliberately vague in their prognoses, Jalland found that few Victorian doctors withheld information concerning terminal illness, ensuring that the sick knew if their sickness was terminal.18 Jalland’s examination of death and dying among elite families points to the publication of William Munk’s Euthanasia: or Medical Treatment in Aid of an Easy Death (1887) as a landmark in medical care of the dying. Munk advocated a system of medicine geared towards soothing the dying. This ranged from encouraging simple measures that relieved some discomfort, such as opening windows for fresh air and light, responding to the patient’s need for food and water, promoting the use of opium for pain relief, and avoiding treatment that would prolong the dying process, to encouraging peacefulness and dignity by urging loved ones to avoid displays of grief or curiosity at the bedside.19 It is possible to view Munk’s text as a bridge between two eras of approaches to dying. On the one hand, his book was rooted in respect for previous generations of physicians and his own Catholicism that sought to reconcile the religious with the medical. Yet Euthanasia, which in a nineteenth-century context referred to easing rather than hastening death, also looked forward to the increasing prominence of medicine in providing palliative care, not necessarily as a separate or entirely secular entity, and to enhancing the holistic care of the dying. In a similar vein, the growing significance attached to good nursing in the second half of the nineteenth century demonstrates the cooperation between different agencies and the persistence of a dual conception of care for body and mind. Jalland estimates that from the establishment of Florence Nightingale’s training school for nurses in 1860, through to voluntary hospitals’ promotion of trained nurses, there were almost 70,000 nurses in England and Wales by 1900.20 Outside hospitals, trained nurses were increasingly employed primarily by affluent families to support family members in the burden of care for the terminally sick and to oversee the care of the corpse. Similarly, increasing numbers of district nurses such as M. E. Loane, a prolific author of books relating her experiences of and insights into social conditions, shared nursing tasks with members

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of poorer families on a more infrequent and itinerant basis. In Loane’s view, the rationale in nursing provision for the poor was to maintain hygiene, administer medication, advise on nutrition and economy, but also to offer respite and emotional support for the sick, the dying, and the bereaved.21 Advances in medical knowledge and provision towards the close of the Victorian period do not necessarily, however, tally with the recession of religion. The Enlightenment posited a rational framework for discussing death and expanded the range of symbolism available for culturally marking death. In Britain, the 1851 religious census indicated declining church attendance. Yet we should by no means take secularization for granted. Recent studies have argued that not only was religion pervasive in everyday life for much of the nineteenth and early twentieth centuries, but, also, that spiritual belief was more amorphous and tenacious than analysis of church attendance figures suggest.22 Indeed, boom periods in spiritualism in the first half of the twentieth century, even to the point where the Church of England organized a committee to investigate the uses and extent of spiritualism in boosting congregations, suggest a popular desire for belief in the perpetuity of the soul and an afterlife that shaped responses to dying and death.23 Similarly, those who did not attend church might seek spiritual solace from a minister, neighbours, or friends as death approached. Despite apparently declining numbers of church attendance from the nineteenth century onwards, the vast majority of the British population continued to request a religious burial service into the second half of the twentieth century. Indeed, analysis of humanist or secular rites of burial and mourning from the late eighteenth century highlights the challenges groups experienced in creating a non-religious language that give meaning to death and offered consolation.24 In many Western European countries, increasing multiculturalism at the dawn of the twenty-first century suggests that religion is far from irrelevant to death and dying. Much of the debate on the interplay between medicine and religion tends to assume a degree of equitable access to representatives of both. Yet among the lower social classes, contact with medical practitioners and clergy was patchy. Many of the criticisms levelled at the Church of England in the wake of declining attendance figures was that ministers had lost contact with labouring members of their parish in a context of swelling populations and urban migration. Non-conformist populations grew in the nineteenth century but some of this was based upon working-class engagement with the philanthropic services offered by Missions. Catholic and Jewish populations also grew in relation to migration patterns but, again, contact between religious representatives and a confessional population was shaped by the role of religion in welfare. Similarly, for many of the prewelfare state working classes, medical care was expensive and until 1929 associated with the workhouse and therefore tainted by the stigma of pauperism. Medical treatment in poor law hospitals was also popularly associated with slipshod systems of care, poor quality nursing, dire sanitary standards, and a lack of respect for the dignity of the poor. Additionally, the Anatomy Act 1832 legalized the traffic in unclaimed pauper cadavers to anatomists for dissection. In theory, this meant that when death took place in the workhouse or affiliated hospitals and families and friends did not claim the body and accept

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the costs of burial, cadavers were liable to be sent to anatomy schools prior to internment. Although this was a relatively small number of cadavers (indeed, anatomists continued to complain after the Act that they received too few corpses for dissection), it did not stem popular anxieties, certainly in the decades immediately after the Act, about death in poor law institutions or suspicion of the medical profession’s attitude towards the poor.25 Outside the poor law, voluntary hospitals and dispensaries run by charitable trusts provided access to rudimentary care while many trainee practitioners geared their cheaper fees for working-class and poor patients. Nonetheless, a perennial stereotype of the Victorian and Edwardian lower classes was their reluctance to pay even small amounts for cheap medicines or attention. Social commentators tended to relate this to skewed priorities: families diverted money for health care to swell coffers for a potential funeral. Although there is undoubtedly some truth in this, given popular antipathy to pauper burial, commentators tended to overlook a rationale that calculated the chances of survival against the cost of medicine. It is also important to note that practitioners and medical officers of health were agents of authority who could initiate procedures to forcibly remove the sick or the dead from family homes. Rather than pitching medicine against religion in an historical chronology of attitudes to death, it is perhaps more helpful to view medicine and religion, first, as nonstatic paradigms that helped shape social, cultural, and political understandings of death and, second, as models that the dying and bereaved have engaged with in diverse ways in different contexts. As studies of Victorian culture indicate, contemporary scientists borrowed heavily from the arts and religion in shaping their imagination of the physical world. The language of science and medicine was suffused with poetry that rendered medical conditions and physiology gendered and emotive; for instance, as specialist interest in cardiac care identified heart disease as a modern urban phenomenon, it was increasingly perceived to be a problem rooted in the ‘passions of men’.26 Disease and causes of death were loaded with cultural connotations from obvious associations between venereal disease and wantonness, to the supposed romance of consumption, to the moral stigma of pandemic diseases such as smallpox.27 It is improbable that medical and clerical practitioners were immune from such associations. Likewise, studies of shifting conventions in anatomical drawings from a dynamic and sneering corpse who featured in caricatures and morality tales as much as medical texts to a static skeleton devoid of emotion suggest changing medical ethics.28 Moreover, as James Milton highlights in his excellent study of medicine and the care of the dying, a process of secularization, in terms of institutional religion, is inseparable from one of ‘sacralization’. In this sense, it is possible to see the hospice movement as both an example of and response to the medicalization of death. Milton identifies the peak of the medicalization of death, the 1960s, as the period at which a hospice movement dedicated to catering for the spiritual and medical needs of the dying took off.29 Similarly, the first modern hospices were established by Christian organizations from the mid-nineteenth century onwards to cater for marginal groups neglected by medical practitioners: L’Association des Dames de Calvaire in Lyon, France (1842); the Irish Sisters of Charity hospice in Dublin (1879); and in London, St. Luke’s Home for the

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Dying Poor (1893) and St. Joseph’s Hospice (1905). One of the ironies of expanding medical expertise and specialism was that as the focus of medicine shifted from palliative care to seeking cure, doctors appeared to take little interest in those deemed incurable. More especially, hospitals dedicated to treating patients were deemed inappropriate and expensive holding centres for the dying. The establishment of charitable homes for the dying sought to fill this gap, especially for the poor, removing them from overcrowded and insanitary environments and offering religious sustenance. Crucially, the homes were not the hated workhouse. As Clare Humphreys notes, however, the religious, philanthropic, and moral focus of early hospices meant that, although they worked with medical practitioners, they did not exploit modern medical techniques for managing pain, such as the increasing use of morphine.30 By the 1930s, increasing criticism that doctors shifted responsibility for care of the dying to relatives was seemingly underpinned by the formation of voluntary euthanasia societies in Britain (1936) and America (1937). In contrast to nineteenth-century understandings of the term as easing the distress of the dying, these societies embraced a definition of euthanasia that promoted the wilful termination of life when appealed for by a patient. Milton points to two key surveys in the aftermath of the formation of the National Health Service (NHS) in Britain that indicated the shortcomings of care for the dying. First, a national survey in 1951 of cancer patients under the auspices of Marie Curie Memorial and the Queen’s Institute of District Nursing demonstrated that many of the poor were unaware of assistance available to them or unsure how to access services on the new NHS. A second survey conducted by an army doctor, H. L. Glyn Hughes, in 1957–8 highlighted a gap in policy for provision of services for the terminally ill. According to Hughes’s survey, 40 of deaths in 1956 occurred in hospital. Of the remaining 60, most deaths took place at home. Where death occurred in homes for the dying, Hughes lamented the lack of medical training that resulted in patients being cared for spiritually but often finding staff unable to assist them in managing their pain.31 Milton points to a growing awareness among the medical profession that, as numbers of deaths in hospital increased, medical practitioners received less training and accumulated less experience in dealing with the emotional trauma of dying or addressing patients’ psychological needs. It was in this context that Cicely Saunders (1918–2005) launched the movement for the modern hospice: a home for the dying that would provide a holistic package of palliative care that recognized and addressed medical, psychological, spiritual, and emotional needs. Drawing on the increasing availability of systematic research into the care of the dying, including patient narratives, Saunders and supporters of palliative reform sought to replace the fatalism of medical practitioners towards the dying with pro-active support. A trained nurse, medical social worker, and finally a physician, Saunders’ conception of dying extended beyond the collapse of a body’s vital functions to include a psychological and spiritual process of separation and preparation: the dying not only required help managing pain, they needed compassion and emotional support too. As a Christian with medical expertise, Saunders’ vision for the modern hospice embodied the fusion of what David Clark calls ‘hard headed’ secular and medical needs with the

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sacred and psychological. Further, while acknowledging localized variations in hospice care since the earliest institutions were established, Clark also notes that the global expansion of hospices tends to share common features, not least in supporting the need for sophisticated medical technology while promoting hospices as a kind of charismatic movement with an imagined history of compassion dating back to early medieval times and inspirational leaders.32 If dying in the nineteenth and twentieth centuries was perceived as a contested site between the secular and the sacred, disposal of the dead was not immune from such debates either. Prior to the rapid urbanization of the late eighteenth and early nineteenth centuries, burial was typified by interment in ground belonging to the established church. The mourning paraphernalia available to mark the passing of the dead ranged from elaborate heraldic funerals among the upper echelons of society to simple burials in shrouds among those lower down the scale. Burial grounds tended to be located at the heart of population centres. Several factors are usually identified as changing burial practice from the eighteenth century onwards: the Enlightenment, sanitary concerns about overcrowded graveyards, and the increasing pluralism of religious and atheistic belief.33 According to James Curl, writing in the 1970s, the establishment of the commercial cemetery sprang from interest in Romanticism and the desire to civilize the populace. The late eighteenth and early nineteenth centuries witnessed a cultural fascination with the sensibilities of death: the melancholic celebration of grief in artistic forms; the glamorization of suicide; and the idealization of forms of disease, notably consumption, as alluring. The Romantic interlude in death cultures is associated largely with key figures, such as Lord Byron (1788–1824), Thomas Chatterton (1752–70), or the poem ‘Night thoughts on life, death and immortality’ by Edward Young (1683–1765). While it is unlikely that such figures bore much relevance for poorer classes’ approaches to death, the Romantics did have more prosaic outcomes. In particular, their inspiration in the landscaping of European cemeteries and, post-Enlightenment, the increasing availability of non-religious motifs, especially neo-classicism, was tangible. The foundation of ‘garden’ cemeteries, notably Père Lachaise in Paris, promoted quixotic reflections on the departed but also lent artistic gloss to a growing utilitarian call for the closure of old churchyards.34 The expansion of private cemeteries was driven by complex and overlapping dynamics: motives included Dissenters’ protests concerning the near-monopoly of the established church on burial privilege, the desire to secure corpses from body snatchers working for anatomists, and the drive to use commercial space as a landscape for the expression of a secular identity.35 More recently, Patrick Joyce has examined the cemetery in terms of liberal governmentality, suggesting that the organization of the dead in commercial burial space was inextricable from conceptions of the city as a body needing careful regulation to maintain healthiness.36 Indeed, the sanitary issues raised by reports on overcrowded graveyards, such as the London doctor George Walker’s Gatherings from Graveyards (1839), made the creation of extra-mural burial sites imperative. The call for the closure of old churchyards and the establishment of new cemeteries located

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outside population centres was underpinned by concern for the dignity of the dead, certainly, but also by anxieties about the negative miasmic effects of half-buried bodies. Collating examples of interment from across Europe to highlight the horrific and unhygienic state of British intra-mural burial, Walker drew on the rhetorical tropes of gothic horror, recounting half-rotted corpses protruding from the ground, and married them with a modern medical sensibility that called for burial reform as a matter of sanitary emergency. Walker’s claims were further endorsed by Edwin Chadwick in a special government inquiry into interment in towns in 1843, a supplementary investigation to the 1842 committee on the sanitary conditions of the labouring population in towns. Walker’s and Chadwick’s legacy was a body of public health legislation: the 1852 Metropolitan Burial Act and subsequent legislation for the provinces granted local governments the power to close existing burial grounds and establish municipal burial boards charged with opening and operating public cemeteries. Importantly, Walker and Chadwick were also pivotal in redefining the corpse as a source of contagion. In addition to providing a solution to the burial crisis, private cemeteries were usually established by joint-stock companies, a phenomenon that moved the business of interment from the near-monopoly of the Anglican Church into a commercial and multidenominational arena. In Britain, the first private cemeteries such as Rosary Hill, Norwich (1819), Chorlton in Manchester (1821), and Low Hill in Liverpool (1825) were established for inter-denominational burial. As Thomas Laqueur has argued, interment in a cemetery run exclusively for profit was ‘a sign that the underlying cultural assumptions of capitalism had taken root’.37 It is widely acknowledged that the Victorian burial ground represented a mirror on the urban landscape: prestigious plots with expensive monuments echoed the spatial arrangement of affluent suburbs; pauper graves were analogous to slum tenements.38 Cemeteries such as Kensal Green (1833) and Highgate (1839) in London were deliberately marketed as ‘society’ graves, while expensive catacombs presented an opportunity for a luxury purchase. It is, however, possible to exaggerate the secular elements of the cemetery: the emphasis on change overlooks continuities in burial practice, not least the overwhelming tendency for most burial parties to request some form of religious burial service, for significant portions of public cemeteries to be assigned to the established church, and for families to express denominational affiliation through selection of grave space. Similarly, the majority of grave markers continued to draw on a religious language and symbolism until the middle of the twentieth century. It is notable that while hygiene was a key motor for the formation of cemeteries, especially at government level, the popular appeal of the cemetery lay in religious freedom, dignity for the dead and social competitiveness rather than hygiene. As the campaign for cremation demonstrates, a populace may appreciate sanitation but it is not the imaginative framework in which they locate death. The promotion of cremation in Britain by Sir Henry Thompson (1820–1904), surgeon to Queen Victoria, from the publication of his book The Treatment of the Body after Death (1874) and the formation of the Cremation Society in the same year focused primarily on the superior hygiene and economy of burning the dead. Cremation propaganda located the sanitary benefits within an ancient

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trajectory of cremation as a civilized form of disposal. Sanitation had limited appeal, however, within a predominantly Christian context (especially in Catholic countries), whereby interment was associated with Christ’s death and bodily resurrection and made little acknowledgement of the importance of custom for catharsis and compassion. Indeed, from the close of the nineteenth century, the discourse of cremation shifted emphasis from sanitation to egalitarianism and respect for the dead, locating the modernity of cremation within a symbolic tradition of Christian burial, notably in the architectural resemblance of crematoria to churches and the emphasis on continuities in customary rites of passage.

Conclusion Few commentators have viewed the professionalization of death in the twentieth century as a positive shift, not least for the intimate dynamics surrounding death: hospital wards are public and hastily drawn curtains offer only token privacy; hospital equipment and coffins present a barrier to holding, touching, and kissing the dying and dead; the intermittent presence of medical staff is not entirely conducive to intimate final gestures; and mortuary facilities, even in funeral directors’ chapels of rest, are contrived, awkward spaces that have little connection with the personality of the deceased. Yet the negative view partially depends on a potentially romanticized perception of home-based death. Undoubtedly, dying at home offers families intimacy or enables them to police access to the dying. Domesticity also facilitates a sense of familiarity for the dying. However, home-based deaths also create a burden of care on those close to the dying with, sometimes, little opportunity for respite. Likewise, the presence of family members is not automatically soothing. When Ada, Lady Lovelace, was terminally ill with ovarian cancer for eighteen months before dying in 1852, her mother and husband clashed repeatedly for control over Ada’s sickbed and her desire to die without God.39 Further, the notion of ‘home’ is loaded with connotations of comfort and intimacy, but for some ‘home’ was overcrowded, insanitary, and potentially highly infectious. In one of the few essays to herald the twentieth-century cultures of death as positive, David Cannadine took issue with Gorer and Ariès to argue that, far from being intrinsically bad for cultures of death and grief, the twentieth century broke free from Victorian consumerism and maudlin delight in death. Yet Cannadine defined the interwar period as one, not of professionalization and medicalization as such, but, rather, as a period of privatization. To illustrate his point, Cannadine turned to the outpouring of subdued but harrowing grief of elite families in the aftermath of World War I. Cannadine pointed to the increasing privatization of grief in this context as a good thing: the focus on personal and individual feelings alongside some families’ desperate search for consolation through the medium of spiritualism rang with authenticity when contrasted with the sham of Victorian extravagance. Cannadine’s view depends, however, on accepting the

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vocal criticisms of a small but prominent group of contemporary campaigners for funeral reform that ostentatious send-offs were the norm. Jalland’s analysis of elite families’ mourning and my own study of working-class funeral customs suggest that depictions of what Cannadine disparagingly called the Victorian ‘commercial bonanza’ in death need revision.40 The assumption within the medicalization of death narrative that a privatization of grief did take place in the twentieth century has been contested. For example, while the hospital and the practitioner took an increasingly prominent role in death cultures in the twentieth century, this does not amount to a medicalization of death and dying in a total sense. Medicine provided a language to talk about death in public but it did not become the only language for talking about death; it existed within a broad spectrum of discourse available to make sense of death. Jupp and Walter in particular question the extent to which historians can so confidently read an increasing professionalization of death services as a period of privatization or a negative culture that made death taboo when so little research on attitudes after the Great War has been carried out.41 The research that does look forward into the twentieth century tends to stress continuities as much as it highlights change. For instance, the enactment of silence that became synonymous with mourning and remembrance during and after the Great War had been a common feature of working-class culture prior to the war. Interment policy during the Blitz in Britain highlighted anxieties for hygiene but also pointed to local and national government sensitivity concerning ownership of corpses that was reminiscent of popular antipathy to the pauper grave.42 Research into state-funded burials in the late twentieth century also demonstrated the persistent antipathy of the poor to ‘pauper’ or public burial and the investment of extra-economic meanings into burial for those on the margins of society, something reminiscent of attitudes towards burial under the old and new poor laws.43 Walter has suggested that the latter decades of the twentieth century witnessed a revival of death. A proliferation of publications concerned with death and the boom in academic ‘death studies’ by the 1990s indicated that far from being taboo, death ‘is everywhere’. If anything was missing from a public discourse of death in the twentieth century it was personal narratives of loss. Yet even this appears to have undergone a revival.44 Recent historical interest in affect in relation to death has suggested that emotional narratives are situational. Apparent absences in the history of death, notably amongst the poor who lacked a rich vocabulary for expressing feelings, are suggestive of alternative languages for loss rather than their non-existence.45 The representation of mass mourning in the British media after the death of Diana, Princess of Wales, in 1997, and in 2009 for a reality television star, Jade Goody, indicate a wealth of diverse narratives (sentimental, heroic, tragic, melodramatic, and comic) available for talking about loss and grief for those intimate with the deceased and, more notably, those who were not.46 Philip Mellor posits a more fluid paradigm based on the presence and absence of death in twentieth-century culture: the sequestering of death from public space highlights modernity’s fixation with control, which, in turn, makes death’s presence in private space threatening.47 Like Kellehear’s pitch for

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the notion of ‘managed’ deaths over ‘good’ ones, the model for the presence and absence of death can be used in a more flexible approach to appreciating the complex, interwoven character of social, medical, and cultural attitudes to death to aim for a history that is not written in binary opposites (good/bad death, sacred/science, priest/ practitioner, individual/community, public/private), but which seeks to read death within particular contexts.

Notes 1. Lindsey Prior, The Social Organisation of Death (Basingstoke: Palgrave, 1989). 2. Pat Jalland, Death in the Victorian Family (Oxford: Oxford University Press, 1996). 3. Robert Dolling, Ten Years in a Portsmouth Slum (London: Swan Sonnenschein, 1896); Charles E. Osborne, The Life of Father Dolling (London: Edward Arnold, 1903). 4. Jalland, Death in the Victorian Family, 128–39. 5. Paul Binski, Medieval Death: Ritual and Representation (London: British Museum Press, 1996). 6. R. Huntington and P. Metcalf, Celebrations of Death: The Anthropology of Mortuary Ritual (Cambridge: Cambridge University Press, 1979); Douglas Davies, Death, Ritual and Belief: The Rhetoric of Funerary Rites (London: Cassell, 1997). 7. Thomas Ksleman, Death and the Afterlife in Modern France (Princeton: Princeton University Press, 1993). 8. M. Murphy and T. MacDonald, Sleepless Souls: Suicide in Early Modern England (Oxford: Clarendon, 1990); Victor Bailey, This Rash Act: Suicide across the Life Cycle in the Victorian City (Stanford: Stanford University Press, 1998); Jalland, Death in the Victorian Family, 59–76. 9. Alan Kellehear, A Social History of Dying (Cambridge: Cambridge University Press, 2007); idem (ed.), The Study of Dying: From Autonomy to Transformation (Cambridge: Cambridge University Press, 2009). 10. Sasha Handley, Visions of an Unseen World: Ghost Beliefs and Ghost Stories in EighteenthCentury England (London: Pickering and Chatto, 2007). 11. Phillipe Ariès, The Hour of Our Death (New York: Knopf, 1981); Geoffrey Gorer, ‘The Pornography of Death’, Encounter (October 1955), 49–52; idem, Death, Grief and Mourning in Contemporary Britain (London: Cresset Press, 1965). 12. Glennys Howarth, Last Rites: The Work of the Modern Funeral Director (New York: Baywood, 1996). 13. Margaret Stroebe, Robert Hansson, Wolfgang Stroebe, and Henk Schut (eds), Handbook of Bereavement Research: Consequences, Coping and Care (Washington, DC: American Psychological Association Press, 2001). 14. Rosemary Horrox, ‘Purgatory, Prayer and Plague: 1150–1380’, in Peter Jupp and Clare Gittings (eds), Death in England: An Illustrated History (Manchester: Manchester University Press, 1999), 90–118, at 91–2. 15. Ralph Houlbrooke, ‘The Age of Decency: 1660–1760’, in Jupp and Gittings (eds), Death in England, 174–201, at 178; Ralph Houlbrooke, Death, Religion and the Family in England, 1480–1750 (Oxford: Clarendon Press, 1998); Vanessa Harding, The Dead and the Living in Paris and London: 1500–1760 (Cambridge: Cambridge University Press, 2002).

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16. Ian Mortimer, ‘The Triumph of the Doctors: Medical Assistance to the Dying, c.1570–1720’, Transactions of the Royal Historical Society, 15 (2005), 97–116. 17. Roy Porter, Bodies Politic: Disease, Death and Doctors, 1650–1900 (London: Reaktion, 2001). 18. Jalland, Death in the Victorian Family, 77–97. 19. Ibid. 83. 20. Ibid. 103. 21. M. E. Loane, The Queen’s Poor: Life as They Find It in Town and Country (London: Edward Arnold, 1905); eadem, Outlines of Routine in District Nursing (London: Scientific Press, 1905); eadem, From Their Point of View (London: Edward Arnold, 1908). 22. Jeremy Morris,‘The Strange Death of Christian Britain: Another Look at the Secularization Debate’, Historical Journal, 46(4) (2003), 963–76. 23. Jennifer Hazelgrove, Spiritualism and British Society between the Wars (Manchester: Manchester University Press, 2000). 24. David Nash, ‘Look in Her Face and Lose Thy Dread of Dying: The Ideological Importance of Death to the Secularist Community in Nineteenth-Century Britain’, Journal of Religious History, 19(2) (1995), 158–80. 25. Ruth Richardson, Death, Dissection and the Destitute (London: Phoenix Press, [1987] 2001). 26. Kirstie Blair, Victorian Poetry and the Culture of the Heart (Oxford: Clarendon Press, 2006); Fay Alberti, ‘Angina Pectoris and the Arnolds: Emotions and Heart Disease in the Nineteenth Century’, Medical History, 52(2) (2008), 221–36. 27. D. E. Shuttleton, Smallpox and the Literary Imagination, 1660–1820 (Cambridge: Cambridge University Press, 2007); Mary Hotz, Literary Remains: Representations of Death and Burial in Victorian England (New York: State University of New York Press, 2009). 28. Janis Caldwell, ‘The Strange Death of the Animated Cadaver: Changing Conventions in Nineteenth-Century British Anatomical Illustration’, Literature and Medicine, 25(2) (2006), 325–57. 29. James Milton, Medicine and Care of the Dying (Oxford: Oxford University Press, 2007). 30. Clare Humphreys, ‘ “Waiting for the Last Summons”: The Establishment of the First Hospices in England 1878–1914’, Mortality, 6(2) (2001), 146–66. 31. H. L. Glyn Hughes, Peace at Last: A Survey of Terminal Care in the United Kingdom (London: UK and British Commonwealth Press, 1960). 32. David Clark, ‘Hospice in Historical Perspective’, in Glennys Howarth and Oliver Leaman (eds), Encyclopaedia of Death and Dying (London: Routledge, 2001), 245–7; idem, ‘Originating a Movement: Cicely Saunders and the Development of St. Christopher’s Hospice, 1957–67’, Mortality, 3(1) (2000), 43–63. 33. Julien Litten, The English Way of Death: The Common Funeral since 1450 (London: Hale, 1991); Clare Gittings, Death, Burial and the Individual in Early Modern England (London: Croom Helm, 1984). 34. J. Stevens Curl, The Victorian Celebration of Death (Stroud: Sutton, [1972] 2000), 1–36. 35. J. Morgan, ‘The Burial Question in Leeds in the Eighteenth and Nineteenth Centuries’, in R. Houlbrooke (ed.), Death, Ritual and Bereavement (London: Routledge, 1989), 95–104; F. Barker (Introduction) and J. Gay (photographs), Highgate Cemetery: Victorian Valhalla (London: Murray, 1984); P. Jupp, ‘Enon Chapel: No Way For the Dead’, in P. Jupp and

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36. 37.

38.

39. 40. 41. 42. 43. 44. 45. 46. 47.

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G. Howarth (eds), The Changing Face of Death: Historical Accounts of Death and Disposal (Basingstoke: Macmillan, 1997), 90–104. P. Joyce, The Rule of Freedom: Liberalism and the Modern City (London: Verso, 2003), 89–91. T. Laqueur, ‘Cemeteries, Religion and the Culture of Capitalism’, in J. Garnett and C. Matthew (eds), Revival and Religion since 1700 (London: Hambledon, 1993), 183–200, at 185. S. Barnard, To Prove I’m Not Forgot: Living and Dying in a Victorian City (Manchester: Manchester University Press, 1990); H. Murray, This Garden of Death: The History of York Cemetery (York: Friends of York Cemetery, 1991); M. Wade-Matthews, Grave Matters: A Walk through Welford Road Cemetery, Leicester (Loughborough: Heart of Albion Press, 1992). For American comparisons, see: D. Schuyler, ‘The Evolution of the Anglo-American Rural Cemetery: Landscape Architecture as Social and Cultural History’, Journal of Garden History, 4 (1984), 291–304; and J. Mitford, The American Way of Death Revisited (London: Vintage, 1998), 81–100. Jalland, Death in the Victorian Family, 111–13. Julie-Marie Strange, Death, Grief and Poverty, 1870–1914 (Cambridge: Cambridge University Press, 2005). Tony Walter and Peter Jupp, ‘The Healthy Society, 1918–1998’, in Jupp and Gittings (eds), Death in England, 256–82. Julie Rugg, ‘Managing “Civilian Deaths due to War Operations”: Yorkshire Experiences during World War II’, 20th Century British History, 15(2) (2004), 152–73. Mark Drakeford, ‘Last Rights? Funerals, Poverty and Social Exclusion’, Journal of Social Policy, 27(4) (1998), 507–24. Tony Walter, The Revival of Death (London: Routledge, 1994). Strange, Death, Grief and Poverty. Tony Walter (ed.), The Mourning for Diana (London: Berg, 1999). P. Mellor, ‘Death in High Modernity: The Contemporary Presence and Absence of Death’, in D. Clark (ed.), The Sociology of Death: Theory, Culture, Practice (Oxford: Blackwell, 1993), 11–30.

Select Bibliography Binski, Paul, Medieval Death: Ritual and Representation (London: British Museum Press, 1996). Harding, Vanessa, The Dead and the Living in Paris and London: 1500–1760 (Cambridge: Cambridge University Press, 2002). Hotz, Mary, Literary Remains: Representations of Death and Burial in Victorian England (New York: State University of New York Press, 2009). Houlbrooke, Ralph, Death, Religion and the Family in England, 1480–1750 (Oxford: Clarendon Press, 1998). Howarth, Glennys, Last Rites: The Work of the Modern Funeral Director (New York: Baywood, 1996). Jalland, Pat, Death in the Victorian Family (Oxford: Oxford University Press, 1996). Jupp, Peter, and Clare Gittings (eds), Death in England: An Illustrated History (Manchester: Manchester University Press, 1999).

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julie-marie strange

Kellehear, Alan, A Social History of Dying (Cambridge: Cambridge University Press, 2007). Milton, James, Medicine and Care of the Dying (Oxford: Oxford University Press, 2007). Porter, Roy, Bodies Politic: Disease, Death and Doctors, 1650–1900 (London: Reaktion, 2001). Strange, Julie-Marie, Death, Grief and Poverty, 1870–1914 (Cambridge: Cambridge University Press, 2005). Walter, Tony, The Revival of Death (London: Routledge, 1994).

chapter 21

histor ica l demogr a ph y a n d epidemiology: the m eta-na r r ati v e ch a l l enge g raham m ooney

Gathering impetus from the mid-twentieth-century ‘quantitative revolution’ in the social and political sciences, historical demography and epidemiology enjoyed a longish period in the medical historical sun between the late 1960s and the early 1990s. This coincided with widespread scholarly research on, and teaching of, demographic and epidemiologic transition theories, the publication in 1976 of Thomas McKeown’s totemic Modern Rise of Population, ground-breaking and influential work on long-run population change by French demographers and the Cambridge Group for the History of Population and Social Structure, and the emergence of an avowedly interdisciplinary ‘social’ history of medicine. Despite a flowering of quantitatively informed approaches, historical demography and epidemiology’s explanatory capabilities, lack of methodological reflexivity, and reliance on ‘transition’ meta-narratives have come under attack. For example, the impact of research on infant mortality was such that Roger Cooter ruefully commented in 1992 that historical demographers subsumed the whole history of child health and welfare to the history of infant mortality alone. Their overt empiricism and failure to engage with research in other historical fields had caused themselves, social historians, and historians of medicine to become ‘stuck in infancy’. Fifteen years later, Flurin Condrau and Michael Worboys described as chimerical the very notion that Victorian Britain underwent an ‘epidemiological transition’ at all. They argued that there still was a ‘need to disaggregate mortality data by age, sex, place and other variables’.1 To some extent, these critiques foreshadow wider debates in medical history about the ‘end’ of the social history of medicine. They also mirror similar sorts of appraisals of the demographic and epidemiologic parent disciplines by sociologists, anthropologists, and historians.2 As

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Mark Jackson notes in the Introduction to this volume, Robert Woods recently, and somewhat defensively, was compelled to restate that historical demography and medical history really do share a common agenda.3 The first of four main sections in this chapter illustrates that definitions of demography and epidemiology provide some understanding of how they are typically used in medical history. The influence of demographic and epidemiological transition theories is discussed in the next two sections. Extensive research into fertility behaviour in the past has dismantled many aspects of demographic transition. Epidemiological transition has proved somewhat more durable in the face of empirical testing, but it is nonetheless problematically hidebound to a narrative of progress and modernization. In addition to fertility and mortality, attention is given to the complicated relationship between migration and health, a topic that is crucial for understanding patterns of population growth, health, and illness, but is almost ignored by the two theories of transition. The final section outlines some of the ways that innovative research on life-course experiences and famine demography has shaken the trees of long-held medical historical assumptions.

Demography and epidemiology: definitions and their implications The standard definitions of demography and epidemiology are interlinked. Demography is the ‘scientific study of human population, including its size, distribution, and composition’. Epidemiology, meanwhile, is about ‘how disease is distributed in populations and of the factors that influence or determine this distribution’.4 Demography and epidemiology tend to analyse human processes in the aggregate. Head counts and the measurement of vital events—such as births, deaths, marriages, divorces, and migrations—are building blocks; meaning derives from their assemblage, either through time, across space, or into sub-groups such as sex, age, race, and social class. Unsurprisingly, then, studies in historical demography and epidemiology have close affinity to the history of public health. Public health is notoriously difficult to pin down as a discipline (see Christopher Hamlin’s contribution to this volume, Chapter 23), but one of the ways in which it distinguishes itself is through an aggregate-level approach to the problems of ill-health. A common form of evaluation in public health is the calculation of population-based outcomes before, during, and after an intervention. For the most part, and where historical data exist, these calculations—such as mortality rates— are straightforward to make, though labour-intensive. There are some excellent examples of the value of this approach historically. Howard Markel and colleagues demonstrate how the implementation by municipal governments of isolation and quarantine, school closure and the prohibition of public gatherings dampened the influenza mortality rate in US towns and cities during the 1918–19 pandemic.5

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Charting aggregate demographic patterns in the past can re-orient scholars towards the search for plausible explanations of change that have socio-cultural roots. The European Fertility Project at Princeton University produced provincial-, district-, and national-level measures of fertility. Its findings—which confirmed the relative simultaneity of fertility decline from the 1870s across much of the continent—prompted social, economic, and cultural historians to seek mechanisms of fertility change from within the ‘ “cultures of contraception,” specific to place and to time, constantly changing even as they contributed to the quiet revolution’.6 Similarly, the remarkable international congruity of infant mortality decline at the turn of the twentieth century pointed researchers away from mono-causal explanations (such as the provision of milk depots) towards the probable confluence of several factors acting in combination, including infant feeding practices, maternal education and health visiting, better sanitation, and the control of fertility. Exceptions to this pattern of universal infant mortality decline remain underexplored. Uruguay is an example where urbanization in the early twentieth century stultified gains made in the late nineteenth century. The timing of urbanization was crucial, but from the early 1900s the introduction of milk depots, paid pregnancy leave, pasteurization of milk, the sale of breast milk, and the creation of an infant protection office all had an indiscernible impact on the infant mortality rate, which was fixed at around 100 per 1,000 live births. The introduction of family welfare payments in the early 1940s was the straw that finally broke the camel’s back and helped infant mortality resume its decline.7 Robert Woods borrowed from contemporary medical terminology to call investigations like these ‘evidence-based medical history’, advocating demography as constituent of a mixed-method medico-historical approach that treats qualitative and quantitative evidence on equal terms.8 This is a laudable goal and makes intuitive sense, and many scholars, particularly in the broad church of social science history, already practise it. Yet the aggregate nature of much quantitative demographic research limits its explanatory power. As Garrett et al. concede, much of it has been ‘inductive and exploratory’, or, in the words of Robert Woods, ‘thick description’; neither will it truly escape from the ravages of the ecological fallacy, whereby individuals’ behaviour is mistakenly inferred from the statistical observations of the group to which they belong.9 Demographic and epidemiological historians frequently have worked with published censuses and vital statistics that were manipulated as part of a nineteenthcentury biopolitical vision. In Britain, the dominant vision conjured up was overwhelmingly ecological.10 Another obvious implication of aggregating tendencies is that the reliable reconstruction of population dynamics in the past largely depends on the existence and survival of sources that capture as many people and events as possible. While several industrializing countries instituted population censuses around the turn of the nineteenth century, information on births, deaths and marriages is not readily available in most places until the mid-nineteenth century at the earliest; indeed, some states in the USA did not have reliable civil vital registration until the 1930s. Historians are turning their critical attention to the creation, development, and maintenance of these registration systems, some-

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times with surprising conclusions. Libby Schweber demonstrates that, until the depopulation debate reared its head in the wake of the Franco-Prussian war, demography in France remained a descriptive discipline and public hygiene had little use for it. The opposite was the case in Britain, where the accommodation of liberal political economy into the national polity admitted the instrumentality of epi-demographic analyses. Yet, as Eddy Higgs shows, the creation of the General Register Office by an Act of Parliament in 1836 had little to do with the need for a system of national medical statistics; more crucial was the determination of property rights and titles where precise dating of marriage, birth, and death were essential.11 Deficiencies in registration systems that are lamented by demographic and medical historians—the lack of penal compulsion to register vital events, the non-registration of stillbirths, and the failure to collect information about morbidity—are understandable when the initial purpose of the first such system was an institutional structure for the reliable transfer of material assets. Incomplete vital registration continues to hamper the validity of demographic and epidemiological studies in the developing world. But, as Simon Szreter points out, from an historical perspective such imperfections reflect more fundamental concerns about the association between vital registration, social security, and the basic human right to an identity from birth.12 Today’s demographers and epidemiologists have accumulated an arsenal of methods to ‘fill in’ missing data caused by the absence or malfunction of registration systems. Population estimates for periods before census enumerations and vital registration are dependent either on population registers and parochial accounts of baptisms, marriages, and burials, which vary in quality and completeness, or on nominal data from tax records, land holdings, and the like. Linking these sources facilitates family reconstitution and encourages a form of micro-history that integrates demographic change with other social phenomena to produce richly detailed narratives of relatively small areas over time.13 Where enough of these records exist for towns, villages, or rural districts, back- or inverse-projection techniques can extrapolate demographic behaviour at a higher spatial scale. This sort of research has muddied the interpretative power of meta-narratives including demographic and epidemiological transition theories.

Population growth, demographic transition, and fertility control Thomas Malthus introduced a homoeostatic model of population growth in two essays written at the turn of the nineteenth century. He argued that there was a positive relationship between population growth and the price of food. Real incomes fall when food prices rise. One of two things then happens. Fertility reduces because couples choose to delay marriage. This is the preventive check on population growth. The alternative, posi-

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tive check is an increase in mortality. Either of the two checks restores the equilibrium between population and food supply.14 For many commentators, the Malthusian model summarizes the English demographic system up to the eighteenth century. Demographic transition theory’s progressive narrative sprung the Malthusian trap. According to the earliest iterations of the theory in the 1940s, mortality decline was caused by the accumulated effects of socioeconomic advances in agriculture and industry and the ameliorative impact of public health. For most industrialized countries, this decline was initiated about or after the mid-nineteenth century. In lagged response to mortality reduction and increased survivorship, fertility began to fall due to a set of reasons broadly associated with ‘modernity’: individuality, urbanization, increased literacy, and the control of reproduction within marriage. Population growth occurs most rapidly in the stage between the mortality and fertility declines. Despite the chronological primacy of mortality decline, demographic transition theory is ‘ultimately concerned only with fertility’.15 To some extent, the ‘health transition’—discussed below in more detail—plugs that conceptual gap by positing that the main features of mortality decline are associated with increased morbidity, fertility behaviour, population ageing, and the provision of institutions and health services.16 Despite its grounding in the European experience of historical population change, demographic transition theory fails to grant migration and emigration a role in the explanation of population growth. For a number of reasons, historical research on fertility patterns has ‘dramatically shattered’ the dominant consensus about demographic transition that prevailed in the 1950s and 1960s.17 First is the chronological inconvenience that declines in total fertility rates (the average number of children born to a women over her lifetime) preceded mortality decline in some countries: France and the United States are the most commonly cited examples. Then there is dispute about demographic transition theory’s unproblematic association of economic development and fertility decline: examples of fertility reduction in the context of relative underdevelopment include places as far apart as Bulgaria, Chile, and Sri Lanka. There is strong evidence from the Balkans and Sweden that deliberate control of fertility occurred in some parts of Europe before a secular fertility decline began. Vulnerable, landless, and land-poor families in eighteenth-century Scania, for example, responded to food price increases by postponing pregnancy.18 Whether this was achieved by abstinence, coitus interruptus, or induced abortion depended on local attitudes and individual circumstances. There is common historical ground here with qualitative approaches. Susan Klepp uses diaries and letters to remark that financial difficulty, the threat of war, and their own ill-health motivated colonial-era American women to delay childbearing.19 Thus, fluctuations in the economic cycle might be the most obvious times to look for evidence of pre-industrial reproductive control, but it also occurred in non-crisis situations that do not readily reveal themselves to the demographer’s eye. Swedish and Balkan studies do not suggest that pregnancy avoidance occurred in a parity-specific way. Small completed family size was nonetheless commonplace in pre-modern rural communities across the world. The deeper

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significance of these findings is that researchers are liberated from restrictive, preconceived notions that ‘transition’ necessarily occurred.20 Assumptions about who controlled their fertility, how, and why are now undergoing intense scrutiny. We are fully aware of the ways in which fin de siècle commentators integrated evidence of the diminishing birth rate into biologically deterministic notions of ‘degeneration’. An important part of the popular eugenic discourse was the interpretation of noteworthy regional, local, racial, ethnic, and class-based variations in fertility behaviour that historical demographers are only just beginning to unravel. In the case of England and Wales, Garrett et al. reconstructed women’s childbearing history in thirteen localities across the country using individual-level data from the 1911 ‘fertility census’. Within these localities, four types of environment are identified: ‘agricultural’, ‘white collar’, ‘light industry’, and ‘staple industry’. Infant and child mortality rates and reproductive behaviour were sufficiently comparable in these environments to pursue the notion that a patchwork of ‘communication communities’ shaped local demographic regimes: ‘similarly socialized persons and families, sharing in the dialect, body language, manners, norms, and values of a local vernacular’ were overlain by the expectation of an ‘intimate connection between the employment and industrial complexion of a community and its fertility, courtship and nuptiality characteristics’.21 Furthermore, there is evidence from oral histories that during fertility decline, ‘traditional’ methods of contraceptive practice—that is, abstinence and withdrawal—coexisted alongside, and at times supplanted, condoms and caps, which were the most common mechanical devices.22 Taken together, these studies suggest a fruitful ongoing conversation between historical demographers and medical historians of reproduction that goes beyond the basic question of whether couples spaced their births or just stopped having children once they reached an ‘ideal’ family. How, for example, did medical advice about contraception assimilate with popular and vernacular knowledge in these communities and between partners? Despite the persistent accretion of contravening historical evidence, demographic transition remains a core organizational concept in population studies.23 Indeed, it is an essential frame in policy discussions about sub-replacement levels of fertility, the dissipating link between marriage and reproduction, and negative population growth in developed countries. Demographers ask if this is now an additional stage to the classic demographic transition known as a ‘postponement transition’, the consequence of economic uncertainty and market crisis. Or is it an altogether separate ‘second’ demographic transition driven by ideational forces related to post-materialism and post-industrialization? Either way, surely the central question is why couples now suspend their use of contraception to have a child, rather than use contraception to prevent a pregnancy, as was supposedly the case in the past. Historians of medicine might be dispirited and wryly amused in equal measure to know that demographers’ claims about putative stages and additional transitions depend, in part at least, on the acceptance of Philippe Ariès’s hotly disputed thinking about the financial and sentimental value of children during the ‘first’ demographic transition’s fertility decline.24

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Epidemiological change, mortality, and migration Along with the precipitous collapse of high levels of fertility in developing nations over the past half-century, perhaps the most remarkable feature of long-term demographic history is the massive gain in life expectancy over the past 200 years or so. James Riley puts it this way: In 1800, with nearly one billion people alive, life expectancy at birth did not surpass thirty years. By 2000, with more than six billion people alive, life expectancy reached nearly sixty-seven years amidst a continuing rise. This is the crowning achievement of the modern era, surpassing wealth, military power, and political stability in import.25

Whether one agrees or not with Riley’s assessment about the significance of this achievement, using history to establish the causes of rising life expectancy clearly is a task of pressing contemporary political relevance. In his sweeping meta-analysis, Riley concludes that there is no blueprint for increasing survival. National and even local routes to low mortality diverge due to choices made from a suite of six ‘tactics’: public health intervention; medical care; income and wealth generation; nutrition and diet; education and literacy; and the behaviours of households and individuals. Most of these overlap and are interdependent. Riley’s broad array of tactics is at one with the concept of ‘health transition’, which supposedly contrasts the biologically narrow ‘epidemiological transition’ with a wider agenda that incorporates a complex array of social, political, economic, and cultural factors.26 Epidemiological transition was originally formulated by Abdel Omran in 1971 as an alternative to demographic transition theory, which he believed was economically deterministic and reductionist. Omran was a fertility researcher concerned with service delivery. He had connections to the World Health Organization (WHO), which advocated family planning as part of the wider provision of health services. In contrast to many population control agencies in the 1950s and 1960s, the WHO saw maternal health and child survival as prerequisites for fertility decline in the developing world. Thus, epidemiological transition ‘provided a means of medicalizing the [demographic] transition and international development work more generally’.27 Epidemiological transition subsequently has been the subject of multiple understandings and interpretations and is worth considering here in some detail because it has featured heavily in historical research. The theory makes five propositions that characterize long-term mortality improvement. Probably the most familiar to medical historians— certainly the most repeated in the epidemiological literature—is the second proposition, which outlined three main eras of mortality and morbidity change. The first era is an ‘age of pestilence and famine’ in which mortality fluctuates due to pandemics such as the Black Death, recurrent subsistence crises, and war—the Malthusian positive check. The

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second age is one of ‘receding pandemics’ in which outbreaks of infectious diseases such as cholera and smallpox become less frequent and have a limited geographical reach compared with the previous pestilential age. The third, and final, stage is the ‘age of degenerative and man-made diseases’, in which the dominance of infectious diseases is replaced by ailments such as cancer and cardiovascular diseases. It is not difficult, with the benefit of hindsight, to detect shortcomings with this theoretical proposition. Omran rectified one of his own omissions by conceding that class and racial/ethnic differentials in mortality can be maintained or exacerbated by mortality decline. He was also quick to note that the historical experiences of Western nations could not be used to predict future changes in the developing world.28 Nevertheless, he did deploy historical information uncritically, using without question diagnostic categorizations, disease nomenclatures, and published mortality data. The three ‘ages’ are also represented as discrete periods, as if overlap between them is unlikely—though the beginning and end of the second age broadly characterized the long-run shift in public health policy in Europe from quarantine to environmentalism, aspects of which have been avidly pursued by public health historians. Writing in the 1970s, Omran underestimated the disruption to linear, unidirectional progression of mortality decline that can occur when infectious diseases develop antibiotic resistance, viruses mutate, and new diseases emerge. The ‘dual burden’ of disease in developing countries exemplifies these limitations. The 1999 World Health Report outlined a situation whereby noncommunicable diseases and injuries (or the age of ‘delayed degenerative diseases’) now vie with the ‘unfinished agenda’ of persistent infectious diseases, the AIDS crisis, undernutrition, and the complications of childbirth.29 Omran’s other propositions still make for interesting reading because they preempted much of the research in historical epidemiology over the ensuing forty years. The first proposition that ‘epidemiologic transition begins with the major premise that mortality is a fundamental factor in population dynamics’ seems like a banal statement now. But as we have already seen, research on fertility dominated the agenda set by demographic transition theory and to great extent marginalized mortality as an explanatory factor in long-term population growth. Furthermore, findings emerging from the Cambridge Group from the late 1960s pointed towards the primary role of fertility in marriage for pre-industrial population growth. Epidemiological transition theory was meant as a corrective to that. One member of the Cambridge Group, Roger Schofield, notably gave Thomas McKeown’s emphasis on mortality short shrift in his review of The Modern Rise of Population. Along with Tony Wrigley, Schofield undermined McKeown’s dismissal of parish registers as a reliable historical demographic source. In addition, McKeown’s penchant for interpreting pre-industrial mortality backwards from nineteenth-century data was itself deeply suspect.30 The Cambridge Group later granted a more significant role for mortality, but some commentators remain exasperated by the level of attention attracted by what came to be known as ‘the McKeown thesis’.31 That attention was trained mostly on the nineteenth century and McKeown’s argument that better living standards and nutritional improvements held the key for increased survivorship in the Victorian period.

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Challenges to, and support of, the McKeown thesis have been legion and are summarized elsewhere by Simon Szreter, Robert Woods, Bernard Harris, and James Colgrove among others.32 I will highlight just three issues—technical, methodological, and conceptual— and show how they are connected and draw out their wider implications. First, McKeown used percentage reductions in cause-specific age-standardized death rates to measure mortality change. This controls the changing age-structure of the population over time, but so too does life expectancy, which is now the common currency for evaluating mortality change. Life table ‘decomposition’ can be used to highlight the contributions to changes in life expectancy made by different causes of death, age groups, and sex. For example, about 28 of the improvement in female life expectancy in England and Wales between 1871 and 1951 was due to the decline of infectious diseases; this equalled the combined contribution of respiratory tuberculosis and respiratory diseases.33 That young women and children benefit most from reductions in infectious disease—in fact, this was Omran’s third proposition—is hardly in doubt. One of the most remarkable features of mortality improvement in the West was the widening female advantage (Figure 21.1). Female excess mortality from late adolescence to the end of the childbearing years was common in pre-industrial populations across the world.

80

2007–08

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1970–72

70 e0 (years)

65 60 55 50 45

1838–54

40 35 30 0.95

1.00 1.05 Female/male ratio

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figure 21.1 Life expectation at birth (e) and female/male life expectation at birth ratio, England and Wales, 1625–2008. Note: Time periods are not equal. Markers represent the following dates: 1625–49 to 1775–99; 1838–54; 1871–80 to 1901–10; 1910–12 to 2000–2 (excluding 1940–2); and 2007–8. Sources: 1625–1799: E. A. Wrigley, R. S. Davies, J. E. Oeppen, and R. S. Schofield, English Population History from Family Reconstitution 1580–1837 (Cambridge: Cambridge University Press, 1997), Table 6.27, p. 308; 1800–1972: Office for National Statistics, Mortality Statistics: General. Review of the Registrar-General on Deaths in England and Wales, 1998, Series DH1 No. 31 (London: The Stationery Office); 1980–2008: Office for National Statistics, Interim Life Tables, England & Wales, 1980–82 to 2006–08, available at http://www.statistics.gov.uk/downloads/theme_population/Interim_Life/ILTEW0608Reg. xls, accessed 11 June 2010.

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This was not just a question of maternal mortality. Occupational exposures and differential access to resources meant that women were more at risk from respiratory diseases and tuberculosis in early adulthood. Understanding how and why this changed is a complex task that involves exploring biological, economic, and socio-cultural factors across the life-course.34 Second, using national data, McKeown’s methodology downplayed the significance of geography. Variously described as the ‘urban graveyard effect’ and ‘urban penalty’, mortality tended to be much higher in towns and cities. By smoothing over spatial variations, McKeown missed the point that for rapidly urbanizing populations—where the disease pool was repeatedly stirred by migration and urban amenities were stretched to the limit—even a stagnant mortality rate was something of an achievement.35 Life table decomposition again has shown that in Victorian England and Wales declining infectious diseases accounted for more than three-quarters of the increase in life expectancy in urban areas and more than two-thirds of the increase in rural districts. Epidemiological studies that assess the impact of urban sewage systems and water purification measures in Europe and North America in the late nineteenth and early twentieth centuries suggest that these interventions might account for up to 50 of urban mortality decline through reductions in childhood diarrhoeal diseases and typhoid fever and its sequelae.36 Third, but by no means least, the way McKeown conceived the relationship between mortality, economic development, and modernization is questionable. Indeed, historians now treat Omran’s associated fourth proposition—‘shifts in health and disease patterns that characterize the epidemiologic transition are closely associated with the demographic and socioeconomic transitions that constitute the modernization complex’—with a high degree of circumspection; assumptions about a linear relationship are an inevitable construct of transitional thinking. Many authors have discussed the supposedly unproblematic link between improved mortality, rising wages, and industrialization, contending instead that populations suffer adverse health consequences from economic development that can take many decades and a great deal of political will to overcome.37 Historical epidemiology’s predominant role has been to use overall and disaggregated mortality (by age, sex, cause of death, and place) inductively, that is, as an indicator of the proximate influences on health outcomes, so-called proximate because they mediate between the prevailing socioeconomic conditions (distal determinants of health) and the individual. This formulation of causation is familiar to those with knowledge about the types of comparative epidemiology practised across Europe in the early and midnineteenth century by the likes of Rudolf Virchow (1821–1902) in Germany, William Pulteney Alison (1790–1859) and William Farr (1807–83) in Great Britain, and LouisRené Villermé (1782–1863) in France. Recently revived as ‘social epidemiology’, the focus on proximate and distal determinants in contemporary research has been criticized for failing to address the fundamental political, economic, social, and cultural fissures that result in health inequalities.38

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This also presents a challenge to historical epidemiology. To respond adequately requires a move away from ecological studies and towards the creative use of sociodemographic and epidemiological information about individuals, as many of the studies mentioned are already doing. Samuel Preston and Michael Haines’s path-breaking research on the USA at the turn of the twentieth century, for example, demonstrated that race was the single most important determinant of an individual child’s mortality risk.39 A huge amount of information about named individuals in historical censuses is now available electronically on a scale that was almost unimaginable until recently. At the last count, the University of Minnesota’s Population Center alone had accumulated 279 million person records from 130 censuses in 44 different countries.40 In just one example of the potential opportunities, it is possible to match census data to original death certificates (if access is unrestricted) and ‘recreate’ the socioeconomic worlds of risk that people inhabited in the past, down to the level of the neighbourhood, the block, and even the street. Multilevel, geo-coded, cross-sectional analyses of mortality (that is, simultaneously accounting for individual-, household-, and district-level variables) would enable historians to ask questions that are normally the preserve of epidemiologists studying the present day: What was the impact of residential segregation on mortality? Was crowding in a household more important for respiratory diseases than a district’s population density? Do children with siblings at school have a greater risk from infectious disease than children without? Were foreigners living amongst their own ethnic group less prone to premature death than migrants who were more isolated from their country folk? Omran’s fifth proposition sketches three alternative scenarios for epidemiological transition: a ‘classical or western’ model, exemplified by England and Wales and Sweden; an ‘accelerated’ model, as demonstrated by the Japanese example; and a ‘contemporary or delayed’ model, drawing on the experience of Chile and Sri Lanka up to 1970. Omran’s point was that these variations were shaped by ‘the pattern, the pace, the determinants and the consequences of population change’. The dynamic influence of migration on these variations is a glaring omission of both epidemiological and demographic transition theories. The origins and destinations of migrants and emigrants implicitly connect places, so it is perhaps unsurprising that population geographers have led the way in migration research. Migration’s crucial role in population growth and decline has been studied extensively, while the complex and multilayered relationship between migration, health, and medicine has also attracted attention. Nineteenth- and twentieth-century streams of emigration and the proliferation of global travel prompted national governments into a politicized medical response. Screening emerged as a device for preventing the human importation of health threats and articulated nationalistic concerns about degeneracy and deficient citizenship, though implementation of entry restrictions varied according to locality and disease condition. The troubling presence of ethnic migrant groups clearly influenced the direction of public health policy. To name but a few examples from the United States alone, smallpox prevention in Milwaukee, diphtheria campaigns in New York, and bubonic

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plague measures in San Francisco were each inflected with fear of both the foreign individual and the foreign social body.41 For most of these studies, migration is a contextual process around which health policy coalesces. However, several additional questions can be raised about migration and health status. One such issue is the extent to which people move residence to secure better health. Perhaps the best historical illustration is suburbanization in nineteenthcentury Britain, a middle-class response to deteriorating environmental conditions in densely populated inner cities.42 The purchase of a villa in a leafy suburb brought with it better life chances: selective migration redistributed wealth and exacerbated health inequalities. Secondly, a more nuanced understanding is needed of how the characteristics of an individual’s migration history—the reasons for moving, migration’s timing across the lifespan, as a single person or with companions, where from and where to— exposed individuals to differential risks and the accumulation of health insults, also known as ‘scarring’.43 This type of longitudinal information is extremely difficult to reconstruct historically, but amongst other things, it might be an important confounding variable for epidemiological interpretations about the impact of in utero and early life conditions on health in adulthood.

Challenging meta-narratives As we have seen, historical epidemiology and demography frequently deal in large-scale, disputed narratives of change that attempt to summarize and describe major transformations in human history. But they are also controversially plunged into other metanarratives that deserve attention here. Two of significance are famine demography and the impact of early-life conditions on health in later life, a strand of research emanating from the ‘Barker hypothesis’. The hypothesis that bears David Barker’s name (it is also known as the ‘thrifty phenotype hypothesis’) derives from research that demonstrated the positive relationship between low birth-weight and increased risk from coronary heart disease. Subsequent studies showed that other chronic diseases, including hypertension, stroke, and type-2 diabetes were also linked to low birth-weight. While Barker argued for the importance of in utero and immediate post-birth conditions on these illnesses, there is additional evidence to suggest that respiratory tuberculosis, bronchitis, and haemorrhagic stroke have antecedents in exposures to adverse conditions during childhood.44 Compared with ongoing contemporary prospective cohort studies, there is less scope for historians to include in their retrospective analyses a comprehensive range of socioeconomic factors such as parental status, family circumstances, income, behaviours such as smoking, and episodes of sickness. Nonetheless, a set of longitudinal historical studies from China, Denmark, French Canada, Sweden, and the USA recently indicated the potential extent of the early-life risks involved, broadly categorized into family context, socioeconomic stress, and exposure to infection.45 In terms of family context, legitimacy,

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birth order, age of mother at birth, and parental survival are statistically associated with an individual’s risk of death in infancy, childhood, and, it transpires, adulthood. Although it is unclear precisely how all of these measures might compromise an individual’s longevity, such findings about the relationship between some aspects of fertility and mortality have obvious implications for demographic transition discussed earlier. Individuals born into high mortality environments or places undergoing severe economic stress seem to have an increased risk of premature mortality in adulthood. Promising though these studies are, methodological problems remain, some of which appear insurmountable. For example, ecological conditions—such as district level mortality rates and business cycles—stand as proxies for individual exposure to risk in early life. Meanwhile, all-cause infant mortality rates in the past are sometimes used to gauge individual exposure to a variety of infectious diseases, many of which were in fact more fatal in early childhood (1–4 years) than in infancy. However, such epi-demographic research on the relative importance of period and cohort-specific effects on mortality prompt an important policy-related debate about biological determinism, the impact of political, social, and economic influences on health, and how social inequalities in survival are produced.46 These questions also impinge on studies in famine demography. Classic Malthusian theory posits that famine checks population growth. Yet one revelation of recent famine research is that it does not do this anywhere near as effectively as major epidemic events such as the Black Death or the 1918–19 influenza. Overall the revival of a population after famine depends on its level of growth in ‘normal’ times. Populations that grow quickly tend to recover quickly. In some instances, post-famine populations actually increased at a faster rate than before the subsistence crisis began. The Irish famine of the 1740s and the Great Finnish Famine of the 1860s are examples.47 A decrease in fertility is probably a more common characteristic of famine demography than an increase in mortality. Evidence from some European countries implies that couples delayed childbearing when harvests were poor and grain prices increased. Demographers know that the number of births drops because of famine, though obviously there is a time lag following the build-up of famine conditions. There also tends to be a short-term, lagged ‘rebound’ in births after the end of a famine. As with the wider issue of fertility decline discussed earlier, the question is how and why is childbearing postponed? A number of social, psychological, and physiological mechanisms are at work during famine. Coital frequency is reduced as marriage plans are shelved or evaporate because of a death, spouses are separated because of migration, and libido reduces. Severe malnutrition can lead to anovulation in women. Another reason why populations tend to recover quickly is that famine can be geographically restricted and respect national borders (at least compared with epidemics). Nonetheless, many famines have exacted a dreadful human toll: up to 7 million excess deaths in the Indian famine of 1876–9; 9 million excess deaths in the Soviet famine of 1921–2; and between 15 and 25 million excess deaths in the 1959–61 famine in China. Yet these staggering numbers represent national death rates of only 3, 6, and 2 to 4, respectively. A survey recently compiled by Ó Gráda estimates that the worst famine in

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proportionate terms was the 1740–41 Irish famine that killed about one-third of a million people at a rate of 13.48 But what do people die of when they succumb during famine? The answer depends on time and place. When basic hygienic measures and immunizations are maintained in a community faced with famine, a large share of deaths is due to literal starvation and diseases associated with compromised immunity (such as dropsy). This was the case in the war-related famines of the Leningrad siege (1942–3), the Dutch ‘Hungerwinter’ (1944–5), and Axis-occupied Greece (1941–3). Notably, these examples come from relatively developed economies in atypical circumstances and where infectious diseases were under some degree of control in normal times. However, for pre-twentieth century famines in general, in rural Yunnan in 1940–44, and in contemporary sub-Saharan African famines, Ó Gráda writes that ‘in places where infectious disease is endemic in normal times, it wreaks havoc during famines’.49 Two important conclusions emerge. First, almost certainly famines are less frequent now than they were in the past. Does this mean the end of famine as a serious risk to human life? As long as political strife and war threaten economically and climatologically vulnerable populations, then the answer to that is probably not. Yet understanding famine history, including demography and epidemiology, arguably gets us closer to that possibility. Second, by revealing the scale of famine from a demographic perspective, the depths of structural violence, denial, deception, and market speculation are properly exposed: demography and epidemiology can and should be used as tools of social justice.50

Conclusion Demographic and epidemiological research sheds important light on a range of significant issues in the long run of human history, not least on ‘life’ itself. Prominent topics are the timing and causes of fertility control and the uneven spatial chronology of changes in life expectancy that also varied between the sexes, age groups, and racial and ethnic communities. For good and bad, much of this scholarship is tied to the way that data were collected, manipulated, and aggregated for past biopolitical purposes. Despite these limitations, and a corresponding tendency towards ‘thick description’, dominant meta-narratives of transition have been either successfully dismantled or subtly altered through this sort of work. Furthermore, demographic and epidemiological histories are reappraising some long-held assumptions about disease, subsistence crises, and the production of health inequalities. Yet these issues barely scratch the surface of all that is relevant and integral to the history of medicine and contemporary health. Not mentioned here is the important recent work by Robert Woods on the hitherto neglected topic of foetal health, which brings stillbirth, abortion, and miscarriage firmly into the historical demographer’s realm. There is significant current debate about the biological-cum-ecological causes of the

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Black Death. Epidemiological historians have also brought their expertise to bear by evaluating death certification practices in the past, which can tell us a great deal about the social, cultural, and medical influences that shape doctors’ diagnostic competence at any point in time. Another key area is the complex relationship between morbidity and mortality, especially the supposed inflation of the former as the latter goes down. The incorporation of morbidity into measures of population health has been a major task in contemporary policy-related epidemiology. Burden of disease evaluations now emphasize how the ‘quality’ of longer lived lives is affected by age-related disability. With increasing longevity, historical demographers can contribute to our knowledge of how ageing populations take shape and the massive implications this has for the past and future of welfare states, health services, health insurance programmes, and retirement plans.51 Given the variety and depth of research outlined in this chapter, now is an exciting time to embark on epidemiological and demographic research. Substantially more contextual wealth and interpretative power comes with the electronic availability of largescale historical data sets. The aggregates of nation, region, or district are by no means the only scales that can be considered. Understanding the influence of neighbourhoods, streets, households, and families is now within potential reach of those studying the demographic behaviour of individuals in the modern period. Impressively sophisticated methods are being used to exploit the registers of pre-modern populations in Europe and Asia. Nor has there been a much better time to pitch these studies into the medical historical milieu. This might seem a perverse comment given the strength of ‘social’ histories of medicine in the 1970s and 1980s. However, as the best recent research on fertility control demonstrates, quantitatively minded historians can learn much from qualitative sources, particularly oral histories. In the explanatory worlds of epidemiological and demographic history, a great deal remains to be settled.

Notes 1. Roger Cooter, ‘Introduction’, in idem (ed.), In the Name of the Child: Health and Welfare, 1880–1940, (London: Routledge, 1992), 1–18; Flurin Condrau and Michael Worboys, ‘Second Opinions: Epidemics and Infections in Nineteenth-Century Britain’, Social History of Medicine, 20 (1) (2007), 147–58; Graham Mooney, ‘Second Opinions: Infectious Diseases and Epidemiologic Transition in Victorian Britain? Definitely’, Social History of Medicine, 20 (3) (2007), 595–606. 2. Susan Greenhalgh, ‘The Social Construction of Population Science: An Intellectual, Institutional, and Political History of Twentieth Century Demography’, Comparative Studies in Society and History, 38 (1996), 26–66; Simon R. S. Szreter, Hania Sholkamy, and A. Dharmalingam (eds), Categories and Contexts: Anthropological and Historical Studies in Critical Demography (Oxford: Oxford University Press, 2004); Nancy E. Riley and James McCarthy, Demography in the Age of the Postmodern (Cambridge: Cambridge University Press, 2003). 3. Robert I. Woods, ‘Medical and Demographic History: Inseparable?’, Social History of Medicine, 20 (2007), 483–503.

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4. David A. Swanson and Jacob S. Siegel, ‘Introduction’, in eidem (eds), The Methods and Materials of Demography (Amsterdam: Elsevier/Academic Press, 2004), 1–8; Leon Gordis, Epidemiology (Philadelphia: Elsevier/Saunders, 2009). 5. Howard Markel, H. B. Lipman, J. A. Navarro, et al., ‘Nonpharmaceutical Interventions Implemented by US Cities during the 1918–1919 Influenza Pandemic’, Journal of the American Medical Association, 298 (6) (2007), 644–54. 6. John R. Gillis, Louise A. Tilly, and David Levine (eds), The European Experience of Declining Fertility, 1850–1970: The Quiet Revolution (Cambridge, MA: Blackwell, 1992), 2–9, at 9; Ansley J. Coale and Susan Cotts Watkins (eds), The Decline of Fertility in Europe: The Revised Proceedings of a Conference on the Princeton European Fertility Project (Princeton: Princeton University Press, 1986). 7. Carlo A. Corsini and Pier Paolo Viazzo (eds), The Decline of Infant and Child Mortality: The European Experience, 1750–1990 (The Hague: Kluwer Law International, 1997); Eilidh Garrett, Chris Galley, Nicola Shelton, and Robert I. Woods (eds), Infant Mortality: A Continuing Social Problem (Aldershot: Ashgate, 2006); Anne-Emanuelle Birn, ‘Doctors on Record: Uruguay’s Infant Mortality Stagnation and its Remedies, 1895–1945’, Bulletin of the History of Medicine, 82 (2) (2008), 311–54. 8. Woods,‘Medical and Demographic History’; Harry M. Marks,‘Fatal Years: An Introduction to the Symposium’, Bulletin of the History of Medicine, 68 (1994), 86–94. 9. Eilidh Garrett, Alice Reid, Kevin Schürer, and Simon R. S. Szreter, Changing Family Size in England and Wales: Place, Class and Demography, 1891–1911 (Cambridge: Cambridge University Press, 2001); Robert I. Woods, The Demography of Victorian England and Wales (Cambridge: Cambridge University Press, 2000). 10. Gerry Kearns, ‘The History of Medical Geography after Foucault’, in Jeremy W. Crampton and Stuart Elden (eds), Space, Knowledge and Power: Foucault and Geography (Aldershot: Ashgate, 2007), 283–309; Simon R. S. Szreter, Fertility, Class and Gender in Britain, 1860– 1940 (Cambridge: Cambridge University Press, 1996); Robert I. Woods and Nicola Shelton, An Atlas of Victorian Mortality (Liverpool: Liverpool University Press, 1997). 11. Michael R. Haines, ‘The White Population of the United States, 1790–1920’, in Michael R. Haines and Richard H. Steckel (eds), The Population History of North America (Cambridge: Cambridge University Press, 2000), 305–70; Libby Schweber, Disciplining Statistics: Demography and Vital Statistics in France and England, 1830–1885 (Durham, NC: Duke University Press, 2006); Edward Higgs, Life, Death and Statistics: Civil Registration, Censuses and the Work of the General Register Office, 1836–1952 (Hatfield: Local Population Studies, 2004). 12. Simon R. S. Szreter, ‘The Right of Registration: Development, Identity Registration, and Social Security—A Historical Perspective’, World Development, 35 (1) (2007), 67–86. 13. M. Fleury and L. Henry, Des registres paroissiaux à l’histoire de la population. Manuel de dépouillemenet d’exploitation de l’état civil ancien (Paris: INED, 1956); Barry Reay, Microhistories: Demography, Society, and Culture in Rural England, 1800–1930 (New York: Cambridge University Press, 1996); James Z. Lee and Cameron Campbell, Fate and Fortune in Rural China: Social Organization and Population Behaviour in Liaoning, 1774– 1873 (Cambridge: Cambridge University Press, 1997); John E. Knodel, Demographic Behaviour in the Past: A Study of Fourteen German Village Populations in the Eighteenth and Nineteenth Centuries (Cambridge: Cambridge University Press, 1988). 14. Thomas Robert Malthus, An Essay on the Principle of Population (London: J. Johnson, 1798); idem, An Essay on the Principle of Population: Or, A View of its Past and Present Effects on Human Happiness (London: J. Johnson, 1803).

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15. Jean-Claude Chesnais, The Demographic Transition: Stages, Patterns, and Economic Implications: A Longitudinal Study of Sixty-Seven Countries Covering the Period 1720–1984 (Oxford: Clarendon Press, 1992). 16. K. Davis, ‘The World Demographic Transition’, Annals of the American Academy of Political and Social Science, 237 (1945), 1–11; F. W. Notestein, ‘Population: The Long View’, in Theodore W. Schultz (ed.), Food for the World (Chicago: University of Chicago Press, 1946), 36–57. 17. George C. Alter, ‘Theories of Fertility Decline: A Nonspecialist’s Guide to the Current Debate’, in Gillis, Tilly, and Levine (eds), The European Experience of Declining Fertility, 13–27; Matthew James Connelly, Fatal Misconception: The Struggle to Control World Population (Cambridge, MA: Belknap Press of Harvard University Press, 2008). 18. Etienne van de Walle and Virginie De Luca, ‘Birth Prevention in the American and French Fertility Transitions: Contrasts in Knowledge and Practice’, Population and Development Review, 32 (3) (2006), 529–55; E. A. Hammel and Patrick R. Galloway, ‘Structural and Behavioural Changes in the Short Term Preventive Check in the Northwest Balkans in the 18th and 19th Centuries’, European Journal of Population/Revue Européenne De Démographie, 16 (2000), 67–108; Tommy Bengtsson and Martin Dribe, ‘Deliberate Control in a Natural Fertility Population: Southern Sweden, 1766–1864’, Demography, 43 (4) (2006), 727–46. 19. Susan E. Klepp, Revolutionary Conceptions: Women, Fertility, and Family Limitation in America, 1760–1820 (Chapel Hill: University of North Carolina Press, 2009). 20. James Z. Lee and Wang Feng, One Quarter of Humanity: Malthusian Mythology and Chinese Realities, 1700–2000 (Cambridge, MA: Harvard University Press, 1999); Simon R. S. Szreter, ‘The Idea of Demographic Transition and the Study of Fertility Change: A Critical Intellectual History’, Population and Development Review, 19 (4) (1993), 659–701. 21. Garrett, Reid, Schürer, and Szreter, Changing Family Size in England and Wales, 12–13. 22. Kate Fisher, Birth Control, Sex and Marriage in Britain, 1918–1960 (Oxford: Oxford University Press, 2006); Simon R. S. Szreter, Robert A. Nye, and Frans Van Poppel (eds), ‘Special Issue: Fertility and Contraception during the Demographic Transition: Qualitative and Quantitative Approaches’, Journal of Interdisciplinary History, 32 (2) (2003). 23. Jacques Vallin, ‘The End of the Demographic Transition: Relief Or Concern?’, Population and Development Review, 28 (1) (2002), 105–20. 24. Philippe Ariès, Centuries of Childhood: A Social History of Family Life (New York: Knopf, 1962); Ron Lesthaeghe and Johan Surkyn, ‘When History Moves on: The Foundations and Diffusion of the Second Demographic Transition’, in Rukmalie Jayakody, Arland Thornton, and William G. Axinn (eds), International Family Change: Ideational Perspectives (New York: Lawrence Erlbaum, 2008), 81–118; Linda A. Pollock, Forgotten Children: Parent-Child Relations from 1500 to 1900 (Cambridge: Cambridge University Press, 1983) 241–63; Tamara K. Hareven, ‘The History of the Family and the Complexity of Social Change’, American Historical Review, 96 (1991), 95–124. 25. James C. Riley, Rising Life Expectancy: A Global History (Cambridge: Cambridge University Press, 2001), 1. 26. Abdel R. Omran, ‘The Epidemiologic Transition: A Theory of the Epidemiology of Population Change’, Milbank Memorial Fund Quarterly, 49 (4) (1971), 509–38; Julio Frenk, José-Luis Bobadilla, Claudio Stern, Tomas Frejka, and Rafael Lozano, ‘Elements for a Theory of the Health Transition’, in Lincoln C. Chen, Arthur Kleinman, and Norma C. Ware (eds), Health and Social Change an International Perspective (Boston: Department of Population and International Health, Harvard School of Public Health, 1994), 25–49.

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27. George Weisz and Jesse Olszynko-Gryn, ‘The Theory of Epidemiologic Transition: The Origins of a Citation Classic’, Journal of the History of Medicine and Allied Sciences, 65 (2010), 287–326. 28. Abdel R. Omran, ‘Epidemiologic Transition in the United States: The Health Factor in Population Change’, Population Bulletin, 32 (2) (1977), 1–42; Abdel R. Omran, ‘The Epidemiologic Transition Theory: A Preliminary Update’, Journal of Tropical Pediatrics, 29 (1983), 305–16. 29. World Health Organization, The World Health Report 1999: Making a Difference, http:// www.who.int/whr/1999/en/index.html, accessed 15 January 2010; Jacques Vallin, ‘Commentary: “Epidemiologic Transition” Interrupted Or Sweep to the Second Stage of “Health Transition”?’, International Journal of Epidemiology, 36 (2) (2007), 384–6. 30. Thomas McKeown, The Modern Rise of Population (London: Edward Arnold, 1976); Roger Schofield, ‘Review: The Modern Rise of Population’, Population Studies, 31 (1) (1977), 179–81; E. A. Wrigley and R. S. Schofield, The Population History of England, 1541–1871: A Reconstruction (Cambridge: Cambridge University Press, 1981). 31. E. A. Wrigley, R. S. Davies, J. E. Oeppen, and R. S. Schofield, English Population History from Family Reconstitution 1580–1837 (Cambridge: Cambridge University Press, 1997); Emily Grundy, ‘Commentary: The McKeown Debate: Time for Burial’, International Journal of Epidemiology, 34 (3) (2005), 529–33. 32. James Colgrove, ‘The McKeown Thesis: A Historical Controversy and Its Enduring Influence’, American Journal of Public Health, 92 (5) (2002), 725–9; Bernard Harris, ‘Public Health, Nutrition, and the Decline of Mortality: The McKeown Thesis Revisited’, Social History of Medicine, 17 (3) (2004), 379–407; Simon R. S. Szreter, ‘The Importance of Social Intervention in Britain’s Mortality Decline c.1850–1914: A Re-Interpretation of the Role of Public Health’, Social History of Medicine, 1 (1) (1988), 1–37; Robert I. Woods and John Woodward, Urban Disease and Mortality in Nineteenth Century England (London: Batsford Academic and Educational, 1984). 33. Graziella Caselli, ‘Health Transition and Cause-Specific Mortality’, in Roger Schofield, David Sven Reher, and A. Bideau (eds), The Decline of Mortality in Europe (Oxford: Clarendon Press, 1991), 68–96. 34. George C. Alter, Matteo Manfredini, and Paul Nystedt, ‘Gender Differences in Mortality’, in Tommy Bengtsson, Cameron Campbell, and James Z. Lee (eds), Life Under Pressure: Mortality and Living Standards in Europe and Asia, 1700–1900 (Cambridge, MA: MIT Press, 2004), 327–57; Kirsty McNay, Jane Humphries, and Stephan Klasen, ‘Excess Female Mortality in Nineteenth-Century England and Wales: A Regional Analysis’, Social Science History, 29 (4) (2005), 649–81. 35. Michael R. Haines, ‘The Urban Mortality Transition in the United States: 1800–1940’, Annales de démographie historique (2001), 33–64; John Landers, Death and the Metropolis: Studies in the Demographic History of London, 1670–1830 (Cambridge: Cambridge University Press, 1993). 36. Gerry Kearns, ‘Le handicap urbaine et le déclin de la mortalité en Angleterre et au Pays de Galles, 1851–1900’, Annales de démographie historique (1993), 75–105; Joseph P. Ferrie and Werner Troesken, ‘Water and Chicago’s Mortality Transition, 1850–1925’, Explorations in Economic History, 45 (1) (2008), 1–16. 37. Simon R. S. Szreter, ‘Economic Growth, Disruption, Deprivation, Disease, and Death: On the Importance of the Politics of Public Health for Development’, Population and Development Review, 23 (1997), 693–728; Stephen J. Kunitz, ‘Speculations on the European

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38. 39. 40.

41.

42.

43.

44.

45.

46.

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Mortality Decline’, Economic History Review, 36 (1983), 349–64; James C. Riley, Poverty and Life Expectancy: The Jamaica Paradox (Cambridge: Cambridge University Press, 2005); James Z. Lee, Cameron Campbell, and Tommy Bengtsson, ‘New Malthusian Perspectives’, in Bengtsson, Campbell, Lee, et al. (eds), Life Under Pressure, 3–24. Nancy Krieger, ‘Proximal, Distal, and the Politics of Causation: What’s Level Got to do with it?’, American Journal of Public Health, 98 (2) (2008), 221–30. Samuel H. Preston and Michael R. Haines, Fatal Years: Child Mortality in Late NineteenthCentury America (Princeton: Princeton University Press, 1991). Minnesota Population Center, University of Minnesota, Integrated Public Use Microdata Series International (IPUMS International), http://international.ipums.org/international/, accessed 20 April 2010. Alison Bashford (ed.), Medicine at the Border: Disease, Globalization and Security, 1850 to the Present (Basingstoke: Palgrave Macmillan, 2006); Amy L. Fairchild, Science at the Borders: Immigrant Medical Inspection and the Shaping of the Modern Industrial Labor Force (Baltimore: Johns Hopkins University Press, 2003); Alexandra Minna Stern,‘Buildings, Boundaries, and Blood: Medicalization and Nation-Building on the U.S.-Mexico Border, 1910–1930’, Hispanic American Historical Review, 79 (1) (1999), 41–81; John Welshman, ‘Compulsion, Localism, and Pragmatism: The Micro-Politics of Tuberculosis Screening in the United Kingdom, 1950–1965’, Social History of Medicine, 19 (2006), 295–312; Judith Walzer Leavitt, ‘Politics and Public Health: Smallpox in Milwaukee, 1894–1895’, Bulletin of the History of Medicine, 50 (1976), 553–68; Evelynn Maxine Hammonds, Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880–1930 (Baltimore: Johns Hopkins University Press, 1999); Nayan Shah, Contagious Divides: Epidemics and Race in San Francisco’s Chinatown (Berkeley: University of California Press, 2001). Simon R. S. Szreter and Graham Mooney, ‘Urbanisation, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities’, Economic History Review, 50 (1998), 84–112. Samuel H. Preston, Mark E. Hill, and Greg L. Drevenstedt, ‘Childhood Conditions That Predict Survival to Advanced Ages among African–Americans’, Social Science and Medicine, 47 (9) (1998), 1231–46. David J. P. Barker, Mothers, Babies, and Health in Later Life (Edinburgh: Churchill Livingstone, 1998); Martin Lindström and George Davey Smith, ‘A Life Course Perspective to the Modern Secular Mortality Decline and Socio-Economic Differences in Morbidity and Mortality in Sweden’, in Tommy Bengtsson (ed.), Perspectives on Mortality Forecasting, vol. 5 (Stockholm: Swedish Social Insurance Agency, 2006), 9–29. Tommy Bengtsson and Geraldine P. Mineau (eds), ‘Part Special Issue: Early Life Effects on Socioeconomic Performance and Mortality in Later Life: A Full Life Course Approach Using Contemporary and Historical Sources’, Social Science and Medicine, 68 (9) (2009). Bernard Harris, ‘Commentary: “The Child is Father of the Man”: The Relationship between Child Health and Adult Mortality in the 19th and 20th Centuries’, International Journal of Epidemiology, 30 (4) (2001), 688–96; Simon R. S. Szreter and Michael Woolcock, ‘Health by Association? Social Capital, Social Theory, and the Political Economy of Public Health’, International Journal of Epidemiology, 33 (4) (2004), 650–67; Bernard Harris, ‘Health by Association’, International Journal of Epidemiology, 34 (2) (2005), 488–90; Simon R. S. Szreter,‘Author Response: Debating Mortality Trends in 19th Century Britain’, International Journal of Epidemiology, 33 (4) (2004), 705–9; George Davey Smith and John Lynch, ‘Commentary: Social Capital, Social Epidemiology and Disease Aetiology’, International Journal of Epidemiology, 33 (4) (2004), 691–700.

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47. Kari J. Pitkänen, Deprivation and Disease: Mortality during the Great Finnish Famine of the 1860s (Helsinki: Hakapaino Oy, 1993). 48. Cormac Ó Gráda, Famine: A Short History (Princeton: Princeton University Press, 2009); Tim Dyson and Cormac Ó Gráda (eds), Famine Demography: Perspectives from the Past and Present (Oxford: Oxford University Press, 2002). 49. Ó Gráda, Famine, 117; John Barber and Andrei Dzeniskevich (eds), Life and Death in Besieged Leningrad, 1941–1944 (Basingstoke: Palgrave Macmillan, 2004); Violetta Hionidou, Famine and Death in Occupied Greece, 1941–1944 (Cambridge: Cambridge University Press, 2006); John D. Post, ‘Famine, Mortality, and Epidemic Disease in the Process of Modernization’, Economic History Review, 29 (1) (1976), 14–37. 50. Amartya K. Sen, Poverty and Famines: An Essay on Entitlement and Deprivation (Oxford: Clarendon Press, 1988). 51. Robert I. Woods, Death before Birth: Fetal Health and Mortality in Historical Perspective (Oxford: Oxford University Press, 2009); Samuel K. Cohn, The Black Death Transformed: Disease and Culture in Early Renaissance Europe (London: Arnold, 2002); Paul Johnson and Pat Thane (eds), Old Age from Antiquity to Post-Modernity (London: Routledge, 1998); Douglas L. Anderton and Susan Hautaniemi Leonard, ‘Grammars of Death: An Analysis of Nineteenth-Century Literal Causes of Death from the Age of Miasmas to Germ Theory’, Social Science History, 28 (1) (2004), 111–43; Graham Mooney, ‘Diagnostic Spaces: Workhouse, Hospital and Home in Mid-Victorian London’, Social Science History, 33 (3) (2009), 357–90.

Select Bibliography Bengtsson, Tommy, Cameron Campbell, and James Z. Lee, et al., Life under Pressure: Mortality and Living Standards in Europe and Asia, 1700–1900 (Cambridge, MA: MIT Press, 2004). Chesnais, Jean-Claude, The Demographic Transition: Stages, Patterns, and Economic Implications: A Longitudinal Study of Sixty-Seven Countries Covering the Period 1720–1984 (Oxford: Clarendon Press, 1992). Fisher, Kate, Birth Control, Sex and Marriage in Britain, 1918–1960 (Oxford: Oxford University Press, 2006). Gillis, John R., Louise Tilly, and David Levine (eds), The European Experience of Declining Fertility, 1850–1970: The Quiet Revolution (Cambridge, MA: Blackwell, 1992). Haines, Michael R., and Richard H. Steckel (eds), The Population History of North America (Cambridge: Cambridge University Press, 2000). Ó Gráda, Cormac, Famine: A Short History (Princeton, NJ: Princeton University Press, 2009). Riley, James C., Rising Life Expectancy: A Global History (Cambridge: Cambridge University Press, 2001). Szreter, Simon R. S., Health and Wealth: Studies in History and Policy (Rochester, NY: University of Rochester Press, 2005). Woods, Robert I., The Demography of Victorian England and Wales (Cambridge: Cambridge University Press, 2000).

chapter 22

chron ic illn ess a n d dise ase history c arsten t immermann

‘With the expansion of interest in social and cultural history during the past quartercentury,’ Charles Rosenberg suggested in 1992, ‘epidemic disease has become an increasingly well-cultivated research area; the historian of disease no longer needs to feel defensive in seeking to demonstrate the relevance of his or her research matter.’1 The same does not apply to the history of chronic illness. While in recent years a number of excellent histories of individual chronic disorders have been published—chronic conditions appear to lend themselves to the ‘biographies of disease’ approach—few historians of medicine have dealt with the historical phenomenon of chronic illness in the same way as has been the case, since the 1960s, with epidemics.2 Before I discuss why this may be the case, let me start with a few words on nomenclature: I have followed the sociologist Arthur Kleinman and others in distinguishing ‘illness’—the experience—from ‘disease’—an identifiable entity. Illness is the ‘innately human experience of symptoms and suffering’, living with and in many cases dying from what doctors identify as a particular disease entity.3 For ‘chronic’, traditionally meaning ‘persistent’, I have followed Jason Szabo’s recent suggestion to examine conditions characterized in nineteenth-century literature as ‘incurable’.4 The boundaries between these various categories are porous, and similar arguments can be made about approaches to mental illness, but I will focus here on organic conditions.5 Compared with epidemics, why are there so few histories of chronic illness? Historical epidemics produced upheaval and confusion, disrupting normal life. They were cataclysmic events that generated a host of documents, turning studying an epidemic into an excellent means of understanding concerns, sensibilities, and political allegiances in particular places and historical periods.6 Comparison with AIDS in the 1980s added poignancy and topicality. AIDS, in fact, has since been transformed into a chronic disease, as drug treatments have made it manageable but not curable, much like kidney failure or diabetes.7 The history of chronic illness is more unwieldy than that of epidemics and must rely on a different set of sources. There are few cataclysmic events and

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approaches are almost necessarily longue durée. Finding a focus beyond the biographical—the individual disease or the individual patient—can be difficult and changes in nomenclature can pose problems.8 Long-term illness until fairly recently was part of normal lives, structuring rather than disrupting them. It is an interesting historical paradox that while many people have always been ill for long periods, chronic disease as a category emerged in the twentieth century, first in the USA and later elsewhere in the industrialized world. The task of the historian of chronic illness is not made easier by the almost universally held assumption that this is an issue in the very recent history of medicine, while earlier periods are thought to have been plagued predominantly by acute and infectious conditions.9 It is important to remember that sufferers from tuberculosis or syphilis, for example, once touched by the illness, were cursed for the rest of their lives: the illness and its symptoms, abating and recurring, good days and bad days, came to define their biographies—a feature that recent analysts have described as characteristic of the modern chronic illness experience.10 Critics of modernity, such as Ivan Illich in the 1970s, have characterized chronic disease as an effect of civilization, caused by alienating aspects of modern life that disturbed the age-old harmony of man and nature and by the failures of recent medicine.11 However, chronic, incurable illness, leading to slow but apparently inevitable deaths, has a history that long precedes the twentieth century and has been blamed on civilization by many past commentators.12 The history of chronic illness has often been the domain of authors other than historians of medicine. Literary scholars and biographers, for example, studied the illnesses of writers such as Keats or the Brontës, and social historians dealt with the history of poverty and the illnesses of the destitute. Consumption, which has been addressed in both these literatures, and its history are central to my argument. While it is often assumed that tuberculosis and consumption were identical, consumption, I argue, did not disappear when tuberculosis was conquered. Moreover, many of the institutions associated with consumption (and later tuberculosis) were adapted for new purposes, and some of consumption’s cultural meanings transferred to other chronic illnesses in the twentieth century. This chapter is about such continuities and the historical change that has obscured them, above all the belief in medical progress and its power, informed by laboratory research in bacteriology and physiology, replacing the feeling of impotence characterizing earlier medical encounters with incurability. Some wasting illnesses that would have been identified as forms of consumption a generation or two earlier were transformed by medical innovations in the twentieth century, making them manageable and turning them into new paradigm cases for dealing with chronicity. The interwar period and the years after the Second World War were crucial for these transformations. Immediately after the Second World War, tuberculosis figures in the developed world peaked for a last time. With infectious disease in decline, epidemiologists and public health activists, especially in the USA where provision for the long-term ill with limited financial means was particularly poor, focused their interest on noncommunicable disease instead, some suggesting that new epidemics of heart disease or cancer were imminent or had already taken hold. The term ‘chronic’ was increasingly

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used as a synonym for ‘non-communicable’. The acute phases of these ‘new’ chronic diseases were thought to be preceded by long, symptom-free periods, even dormancy, and triggered by various forms of stress—not unlike consumption in the early nineteenth century. The dominant conceptual approaches to chronic disease, thus, still reflected older approaches to consumption. However, while in the seemingly classless society of post-Second World War America chronic disease came to be viewed increasingly as a problem of affluence, British epidemiologists remained interested in the role of poverty in its aetiology. Susan Sontag, writing in the late 1970s, as a contemporary of Illich and basing her arguments mostly on literary sources, compared the metaphors associated with consumption (which she took to be identical with tuberculosis) and cancer.13 I will suggest that the continuities with consumption go beyond metaphors, shaping the ways in which we deal with chronic illness today.

Consumption in an age of incurability Consumption was much more than tuberculosis. As René and Jean Dubos point out in their classic book on The White Plague, much of what was described as consumption in old medical writings was not pulmonary tuberculosis.14 Until the late nineteenth century, when a patient was seen to waste away slowly and seemingly inevitably, the diagnosis was usually consumption. Rather than being synonymous with tuberculosis—a diagnosis that presupposes the identification of tuberculous lesions in post-mortem examinations and, following Robert Koch (1843–1910), the demonstrable presence of a specific bacillus—consumption was associated with the clinical picture of patients deteriorating, sometimes rapidly, sometimes over years. Wasting diseases whose final stages were often characterized as consumption included also scurvy, scrofula, and various forms of cancer. Conditions such as asthma or dropsy were also linked to consumption. Consumption, thus, was not a distinct disease entity, but rather, being consumptive was a personal quality. If an individual had a consumptive diathesis, that is, an inherited proneness to consumption, the illness could be brought on by a variety of precipitating factors.15 Porter and Rousseau provide us with a useful introduction to the unitary nature of health and sickness in early modern medical theories.16 Ideally, if life was lived sensibly and the constitution was kept in a good shape, all bodily processes conspired to maintain an individual’s health. A variety of influences could bring on sickness, including external threats such as epidemic fevers, miasmata, weather changes or injuries, lifestyle factors such as bad diet, bodily neglect, and too much alcohol, and mental states such as overexcitement or depression. How these threats to health affected individuals depended on their constitutions. A strong constitution overcame them quickly and restored the balance of humours. Overindulgence, for example, might merely lead to a salutary attack of gout in an individual with a strong constitution, clearing the blood of purulent matter. In individuals with a weak constitution, be this due to poor inheritance, previous illnesses, or bad habits, the same behaviour might trigger consumption.

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It was thought to be precipitated by cold or damp, fevers, and all sorts of minor respiratory illnesses, as well as emotional shocks, overzealous study, an unhappy love affair, or excessive sexual activity. Once consumptive, an individual could never expect to be cured. Chronic illness signalled a weak constitution irreparably damaged by a life lived carelessly or under unfavourable conditions. Consumption was thus the endpoint of much chronic illness, rooted in an individual’s constitution, triggered by events in their life, and structuring their biography. Consumption holds a special place in the cultural and social history of the long nineteenth century. It shaped the dominant female beauty ideal of the time—ethereal, thin, pale, with a red flush on the cheeks, as depicted in many pre-Raphaelite paintings—and was an important component in the image of the creative artists of the Romantic age.17 The young Keats famously met his fate in Italy, having hoped in vain that the Mediterranean climate would improve his consumptive constitution. Romantic accounts depicted the final stages of consumption as a spiritual process that revealed the essence of the dying human being, the individual’s genius. Consumption was represented as a ‘refined disease’, as Dubos and Dubos put it, ‘in which the mind triumphs over the body’.18 They quote extensively from the writings of the brothers Goncourt, French authors whose novel Madame Gervaisais greatly influenced the young Emile Zola. Consumption transformed their heroine into ‘a mystical character’: In contrast to the diseases of the crude, baser organs of the body, which clog and soil the mind, the imagination, and the very humors of the sick as though with corrupt matter, phthisis, this illness of the lofty and noble parts of the human being, calls forth in the patient a state of elevation, tenderness and love, a new urge to see the good, the beautiful and the ideal in everything, a state of human sublimity which seems almost not to be of this world.19

Novelists frequently used consumption as a dramatic device to dispose of characters.20 Consumptive heroines such as Mimi in La Bohème or Violetta Valéry in La Traviata (based on Marguerite Gautier in Alexandre Dumas’s novel La Dame aux camellias) also came to populate the opera stage. In Emily Brontë’s Wuthering Heights several of the novel’s characters succumb to consumption. Such literary accounts rarely mentioned diarrhoea or other common, less dignified features of the final stages of the illness. Like other nineteenth-century authors, the Brontë sisters were familiar with the consumptive experience. Two sisters, Maria and Elizabeth, succumbed as adolescents, Emily, Anne, and their brother Branwell as young adults, and Charlotte aged thirty-nine. Later in the century, what Dubos and Dubos called an ‘attitude of perverted sentimentalism’ towards the disease gave way to a focus on social problems: consumption was increasingly associated with deprivation. ‘If one roams the streets a little in the early morning’, Friedrich Engels wrote about the working-class districts of Victorian London, ‘when the multitudes are on their way to work, one is amazed at the number of persons who look wholly or half consumptive.’21 Victorian workhouses were filled with often elderly sufferers from incurable illnesses, who had nobody to look after them and did not possess the means to pay for care in their homes. Workhouses were originally designed

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principally for the custody of vagrants, whose pauper tendencies the Victorian Poor Law reformers wanted to discourage.22 The necessity of providing for those genuinely sick and feeble appeared to be ‘an afterthought, an appendage to the main scheme’ to the members of a Sanitary Commission for Investigating the State of the Infirmaries of Workhouses for The Lancet in 1865.23 The commissioners found, however, that: in metropolitan workhouses at present the really able-bodied are enormously inferior in numbers to the sick. For the inmates of the ‘sick wards’ proper form but a small proportion of the diseased persons in every London workhouse. Multitudes of sufferers from chronic diseases, chiefly those of premature old age, crowd the socalled ‘infirm’ wards of the houses, and swell the mortality which is a melancholy characteristic of these establishments. Examples are not uncommon in which the really able-bodied form but a fourth, a sixth, or even an eighth of the total number of inmates. The fate of the ‘infirm’ inmates of crowded workhouses is lamentable in the extreme; they lead a life which would be like that of a vegetable, were it not that it preserves the doubtful privilege of sensibility to pain and mental misery.24

This account points to the broad spectrum of chronic illness and disability evident among the population of a London workhouse. But nineteenth-century medical journals like The Lancet, perhaps surprisingly, also provide us with rich accounts of individual illness experiences. Take the example of Anne Davis, whose story illustrates what it meant for a small shop owner to develop consumption in Victorian London, even though she was lucky enough to be admitted to a voluntary hospital. Mrs Davis was forty-one and had been a widow for ten years when on 12 October 1841 she was admitted to University College Hospital, London, as a patient of Dr John Taylor.25 Dr Taylor found Mrs Davis to be of ‘sanguine nervous temperament’; she had dark hair and eyes, and her habits were regular. A visitor told the nurse that she had been imprisoned lately for debt and suffered from anxiety. She had been in good health until the previous year when she moved into a house that turned out to be damp. The article describes Mrs Davis’s time in the hospital in great detail, her increasing emaciation, anxiety, and breathing difficulties. There is also much detail on diagnostic procedures. Taylor applied the new techniques of percussion and auscultation and concluded that her right lung was diseased. There were four diseases that he felt explained her symptoms: pleurisy, pneumonia, phthisis, or some morbid growth such as cancer. Over the following six weeks the patient’s condition deteriorated, and there was not much the doctors could do about it. She was treated with leeches and belladonna plasters to relieve the pain. A prescribed half-pint of ale made her delirious and had to be omitted. Breathing became very difficult and a gurgling sound could be heard on both sides of the chest. Dr Hare, a pupil of Dr Taylor, described a sound ‘as if the whole lung were breaking up’. On 27 November, she ‘sunk gradually’ and died in the late afternoon. Forty-one hours after Anne Davis’s death, Dr Taylor and his colleagues ‘inspected’ her body. They found that the right chest contained about eight ounces of a thick, grey fluid. They also recorded tumours elsewhere in her body. The ‘foreign matter’ in the right lung was examined under the microscope by Taylor’s colleague, Dr Walter Hayle Walshe

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(1812–92), a recognized expert on both respiratory diseases and the nature and treatment of tumours, who found that it possessed the characteristics of cancer. Thanks to dying in a teaching hospital and a post-mortem examination of her body, Anne Davis’s case now belongs to the history of cancer. Had she only been seen by a local physician, no doubt, her death would have been attributed to pulmonary phthisis or simply consumption. Patient stories like hers—which are not difficult to find in nineteenth-century medical literature—are important because they complement longue durée histories of disease that focus merely on statistical patterns. They tell us what illness meant for individuals and also illustrate the role of individual patients in a historiography of medical progress that has traditionally been written exclusively around contributions by medical researchers.

Transformations of chronic illness in an age of confidence Anne Davis’s story takes us across the threshold to modern medicine. It shows how humoral pathology was giving way to a new, ontological approach to sickness, drawing on the results of dissections to identify specific disease entities, thus leading to increasing differentiation in what had been a continuum of consumption and other forms of illness. Experimental physiology and bacteriology provided means of identifying not only pathological manifestations but causes. With increasing differentiation came a growing confidence that interventions drawing on the new sciences would bring relief if not cure.26 René Théophile Hyacinthe Laennec (1781–1826) is best known for his invention of the stethoscope, the instrument that allowed physicians to use their ears to ‘look’ (as indicated by the term ‘scope’) into a patient’s chest, and for laying the foundation of the modern ontological understanding of tuberculosis as a disease entity, the specific form of consumption that is associated with tubercles in the lung.27 The new understanding of consumption that emerged from Laennec’s clinic, and from the circles of colleagues and friends he interacted with, relied on a combination of careful clinical observation (supported by Laennec’s new instrument, the stethoscope) with routine post-mortem examinations. What defined the disease in the classificatory system promoted by Laennec and his followers was no longer a (potentially infinite) set of symptoms that the physician considered in the context of the patient’s biography, but the existence of a finite number of specific disease markers in the body, found after death and assumed to be present already in the living, causing the illness. As far as chest diseases were concerned, the new definition relied also on the meticulous differentiation of lesions associated with tuberculosis from others picked up by the same diagnostic methods. Tubercles were one form of ‘new growth’ in the lungs, but Laennec and his contemporaries also described

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others, like those found in Anne Davis’s lung. Today these would be diagnosed as cancer; to Laennec they were different forms of phthisis. Dropsy is another ‘forgotten’ sickness, replaced by new diagnoses.28 It had been known since the beginnings of recorded medicine, associated—like consumption— with exposure to cold and heavy drinking. Dropsy made its sufferers swell up grotesquely as their bodies collected fluid in the breast, belly, head, and limbs. They felt constantly thirsty and increasingly suffocated as the fluid pressed onto the lungs, making it impossible to lie down. Tapping—draining the liquid from the abdomen—provided some degree of relief. Like consumption, the diagnosis of dropsy was based on its clinical manifestations and the causes were usually located in the biographies of sufferers. Again, like consumption, dropsy underwent a first set of transformations in the nineteenth century, as a consequence of the systematic association of autopsy findings with clinical observations in living patients by the British physician Richard Bright (1789–1858) at Guy’s Hospital, combined with his observation that urine samples from patients contained albumin. Bright’s disease required a new sort of naming, Steven Peitzman suggests in his excellent ‘biography’ of this disease, ‘because it represented a new way of thinking about and defining disease, which had not existed before the early nineteenth century’.29 Bright’s disease, Peitzman argues, along with the other ‘new’ diseases defined with the help of the new tools, the stethoscope, the laboratory, and the autopsy, represented a shift in the structure of medicine and in doctor–patient relationships.30 While it was obvious to patients when they were suffering from dropsy or consumption, with the new disease entities far more authority rested with physicians or, more abstractly, with medical science. The diagnosis of Bright’s disease in a person with no symptoms, based merely on a urine examination, Peitzman suggests, ‘represented an entirely new manner of transforming a person into a patient . . . The felt bodily sensations of the patient and the patient’s recounted story of them, would increasingly lose their primacy and power.’31 This was the beginning of a new chapter in the history of disease, at the end of which, a century or so later, many would find themselves diagnosed with diseases that often lacked symptoms, following measurements with devices adapted from physiological laboratory instruments for clinical use. Diabetes mellitus provided the model for the next major transformation that turned chronic diseases into entities that, while still not curable, were considered manageable.32 Like dropsy or phthisis, diabetes was known since antiquity. Characterized by unquenchable thirst, copious urination, and wasting of the body, to physicians in ancient Greece this appeared to be a condition where the flesh of sufferers melted into urine. When the constitution of the disease was completely established, they reported, the melting was rapid and death speedy. In the seventeenth century the Englishman Thomas Willis (1621–75) observed that the urine of patients was as sweet as if honey or sugar had been added. A century later, Matthew Dobson (d. 1784), a Liverpool physician, suggested that the sugar was not formed in the kidneys but removed from the patients’ blood, explaining their emaciation. A succession of dietary therapies followed, which attempted to feed sufferers with foods their bodies could assimilate, but with minimal benefits.

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Children under ten years of age could expect to live no more than three years following diagnosis, while elderly patients survived for about twice as long. The outlook for diabetes patients changed radically following the isolation in 1921 of a peptide hormone, insulin, by Frederick Banting (1891–1941), Charles Best (1899–1978), and their colleagues at Toronto University. If the transformation of dropsy into Bright’s disease represented a success for pathological anatomy, the changes in the treatment of diabetes signalled a triumph for experimental physiology and the relatively recent subspecialty of endocrinology. In a classic experiment, in 1889, two Germans then working at the University of Strasbourg, Oskar Minkowski (1858–1931) and Joseph von Mering (1849–1907), had removed a dog’s pancreas and observed that the dog developed symptoms comparable to diabetes in humans. Others found that a particular group of cells in the pancreas, named the Islets of Langerhans after the German who had first described them in 1869, was linked to diabetes. Banting and Best succeeded in preparing an extract of this part of the pancreas and demonstrating that this extract lowered the blood and urine sugar of a dog whose pancreas had been removed. In the following January, only eight months after the initial experiments, they injected 15 cc of a relatively impure beef pancreas extract described as ‘brown muck’ into the buttocks of a fourteen-year old boy, who had been on a strict diet since 1919 and weighed only 65 lb. His blood sugar fell but there was no clear clinical benefit. They repeated the experiment and continued treatment for ten days, resulting in a marked clinical improvement. Reports on the case were initially greeted with scepticism. However, other reports followed, often garnished with ‘before and after’ photographs illustrating the remarkable recovery of the little patients: miserable living skeletons before the treatment became happy-looking children after a few months. Insulin was soon available commercially, produced in the USA by the pharmaceutical company Eli Lilly. In Britain, the Medical Research Council controlled production; the first British insulin was available in 1923. However, insulin was not what the public may have expected from a medicine: it did not cure diabetes. Rather, it allowed patients to live relatively normal lives, but they were reliant on frequent injections until their deaths. Instructing patients to inject themselves appeared outrageous to many doctors in the 1920s, but other forms of application did not work. This appeared to reverse the process in which authority had been transferred from patients to the medical profession over the previous century, but compliance was paramount and patient education important. The practice of self-injection became part of a new normality. As memories of the reality of untreated diabetes faded, the identity of the disease was increasingly constructed not around clinical manifestations but around the practices of calibrating one’s sugar intake, measuring blood sugar, and injecting insulin.33 The identity of renal failure was similarly transformed when, from the 1960s, dialysis was increasingly available to chronic renal patients.34 These new regimes required a high degree of organization and self-discipline. One British diabetes patient compared his life with diabetes to living with a dangerous predator: ‘If you look after it, and never turn your back on it, you can live with a tiger. If you neglect it, it will pounce on you and rip you to shreds.’35 The longterm management of these conditions also led to new medical challenges, when patients

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who would have died after a few years if untreated, developed complications after years of treatment. The obvious success of managing diabetes with frequent self-injections of insulin using hypodermic syringes and accompanied by a strict behavioural regime not only changed the status of diabetes and the identity of its patients, but turned it into a model for the long-term management of other conditions being identified as chronic diseases. When the British clinician Frederick Horace Smirk (1902–91), for example, experimented with the clinical use of the ganglion-blocking drug hexamethonium for the treatment of malignant hypertension at Dunedin Medical School in New Zealand in the early 1950s, he implemented a similar regime, instructing patients to self-inject the drug with tuberculin syringes.36 Smirk was a representative of a new generation of clinicians, confident about the promise of medical science and enthusiastic about new drugs and other products of medical innovation. The regime he developed demonstrated that long-term management of hypertension was possible and beneficial, paving the way for new drugs with less drastic side-effects, allowing treatment for ever lower blood pressure readings.37 Antibiotics since the 1940s cured many chronic infections and shortened hospital stays. Following the antibiotic bonanza, drug companies proved keen to develop the market for cardiovascular drugs and other treatments for chronic illness, which promised stable and long-lasting profits.38

Chronic disease in an age of welfare reform While other wasting diseases became manageable, pulmonary tuberculosis remained a chronic, incurable disease until the mid-twentieth century, despite considerable investments. Robert Koch’s attempt to promote tuberculin as a scientific cure in 1890 had been a disaster.39 The usefulness of surgical interventions—while certainly important for the development of thoracic surgery—remained disputed. Sanatorium treatment was hardly a straightforward tool for managing the disease. Rather, the Magic Mountain experience cemented some of the attributes associated with consumption in the nineteenth century. The antibiotic streptomycin in the 1940s was hailed as a breakthrough for modern science, but it was far from a miracle cure. By then the disease had long been declining in incidence, leading to a controversy in the 1970s (associated with the name of Thomas McKeown) over whether this decline was primarily due to medical progress or to an improvement in living conditions.40 In the absence of a therapeutic breakthrough, tuberculosis was associated with other important developments earlier in the century. In Britain, the 1911 National Insurance Act was partly motivated by concerns over tuberculosis. The Medical Research Council had its roots in this context: its precursor institution, the Medical Research Committee, was established to promote research into this disease. Many of the new welfare services

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in the interwar period were dedicated (besides mother and child provisions) to tuberculosis, and municipal sanatoria and chest hospitals came to complement the old Poor Law hospitals, which still housed most of the elderly in need of care for chronic conditions. In 1948, both the institutions formerly dedicated to the treatment of tuberculosis and the former Poor Law hospitals (municipal since the end of the Poor Law in 1929) became part of the new National Health Service. One former hospital originally for the treatment of children with tuberculosis of the bones, Wrightington near Manchester, turned into an important site in the 1960s for one of the most successful medical innovations of the post-war period, the development of the total hip replacement, which transformed the fate of arthritis sufferers—a growing group of patients in a world where many came to live longer, active lives, making ailments associated with old age more common and problematic.41 Mortality and morbidity patterns had changed significantly by the mid-twentieth century. Deaths in childhood and early adulthood had declined radically; more people lived past middle age, making illnesses associated predominantly with middle and old age, such as heart disease, strokes, or cancer, much more visible. The rise of welfare administrations and the growing costs associated with this development turned the prevention of these conditions into an important issue for public health policy. The middle decades of the century witnessed some striking changes to death patterns among the middle-aged, as illustrated by a graph in the 1962 Report by the Royal College of Physicians on Smoking and Health, depicting mortality from a number of respiratory diseases among men aged 45 to 64. It shows not only that around 1950, for the first time, mortality from tuberculosis in this cohort was lower than that from cancer, but also that lung cancer alone was to blame for the increase in cancer mortality, a disease that by the mid-1950s had been firmly linked to smoking cigarettes (see Figure 22.1).42 Cigarette smoke was one of a number of risk factors associated with cancer and cardiovascular disease later in life that were identified by epidemiologists with new statistical techniques since the 1940s. Others included hypertension and blood cholesterol. A focus on chronic disease and risk factors became characteristic of new approaches to public health.43 The perceived increase in cancer mortality, along with fears about an epidemic of heart disease, had worried especially the American public since the interwar period, feeding into broader concerns with chronic illness. These new fears were supported by statistics, not only traditional mortality data but also new figures compiled by life assurance companies or generated by a series of surveys looking specifically at chronic illness.44 The latter, crucially, also produced data on morbidity. Alarming findings among draftees during the First World War revealed that not only the elderly were affected by chronic, disabling conditions. In fact it may have been the shortage of adequate facilities for patients with long-term illnesses in the USA (compared with the relative abundance of pauper beds in Britain and France, for example) that prompted the emergence of chronic disease as a new, distinct category. The Welfare Council of New York conducted a study in 1928, including a survey of facilities and a census of 20,700 people incapacitated by chronic conditions (excluding tuberculosis, mental problems, blindness, and deafness) and cared for by the city’s medical and welfare agencies. Only one-fifth of these

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STANDARDISED DEATH RATES FROM CANCER, TUBERCULOSIS, & BRONCHITIS MEN AGED 45–64. ENGLAND & WALES 1916 1959

ANNUAL NUMBER OF DEATHS PER 100,000

300

250 CANCER OTHER THAN LUNG

200

LUNG CANCER

150 BRONCHITIS

100 TUBERCULOSIS OF LUNGS

50

0

1916–20 1921–25 1926–30 1931–35 1936–40 1941–45 1946–50 1951–55 1956–59 YEARS [N.B. STANDARDISED TO 1951–52 POPULATION]

figure 22.1 A different perspective on what has come to be known as the epidemiologic transition: death rates from cancer, tuberculosis and bronchitis among middle-aged men in England and Wales, 1916–1959. From: Royal College of Physicians, Smoking and Health (London: Pitman Medical Publishing, 1962), p. 15.

were over 70 years old; more than half were under 45. A three-year study in Massachusetts in 1929 revealed that chronic disease, including cancer and cardiovascular problems, then accounted for two-thirds of all deaths, compared with one-third half a century earlier, resulting in considerable human and economic cost.45 Following the publication of the report on the New York study in 1933, the Welfare Council established a Committee on Chronic Illness, chaired by Ernst P. Boas (1891–1955), a cardiologist and pioneer of geriatric medicine.46 Boas became an activist for the deployment of resources in the fight against this ‘unseen plague’ (the title of a book he published in 1940). With its ageing population, Boas argued, America was facing a social and health crisis to which a public health system focusing on mortality alone could not do justice. He compared chronic illness to ‘dry rot constantly weakening and destroying the social organism’.47 Boas

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championed the building of special hospitals for the chronically sick. However, he and his friends also called for the introduction of universal health insurance, arguing that in order to make medical practice effective, political and economic inequalities and the resulting maldistribution of medical resources had to be addressed. This position was vehemently opposed by the medical mainstream in the USA. There were other surveys and reports that followed, including the National Health Survey of 1935–6, covering 703,092 households in 83 cities, which surprised Americans with the finding that nearly a fifth of the population had a chronic disease or disability.48 A Joint Committee on Chronic Illness was formed in 1945 by the American Hospital Association, the American Medical Association, the American Public Health Organization, and the American Public Welfare Association. This Committee passed on the baton in 1949 to a Commission on Chronic Illness, which published a monumental, four-volume report in 1957.49 A Journal of Chronic Diseases was launched in 1955, extensively quoting from the report of the President’s Commission on the Health Needs of the Nation chaired by the orthopaedic surgeon Paul Magnuson, where ‘much space was devoted to chronic illness and rehabilitation’.50 While in the 1930s many had come to see chronic disease as a national problem that called for a massive social policy response, however, the American approach to chronic illness took a different turn after the war. Memories of the social problems of the interwar period faded and during the early years of the Cold War calls for measures that carried only a faint smell of socialism were best avoided. In a society that tried to ignore class differences, large-scale epidemiological studies such as Framingham focused exclusively on clinical parameters and ignored unwieldy social factors.51 Heart disease and cancer were increasingly associated with affluence, and public health interventions were aimed at educating people individually to reduce their personal risks of developing health problems later in life.52 In Britain the situation was somewhat different. Here too, surveys were conducted, albeit on a smaller scale. A survey commissioned by the Ministry of Health in 1954 focused on the provision of services, finding that the majority of chronic sick beds were in former municipal and Poor Law hospitals that had become part of the National Health Service in 1948.53 While the commission found that the number of beds was sufficient in total, much of the accommodation was unsuitable, in damp buildings with narrow staircases and without lifts, with insufficient bathrooms and dayrooms, and poor heating and lighting. All was still distinctly reminiscent of the workhouse. As in America, patients in these institutions were increasingly medicalized. However, in Britain this led to the development of geriatrics as a specialty, associated, for example, with the work of Lord Amulree (1900–83).54 In Britain, as in the USA, epidemiologists turned to chronic conditions. The work by Richard Doll (1912–2005) and Austin Bradford Hill (1897–1991) on lung cancer and smoking is well known.55 Links with social medicine remained close. The Medical Research Council funded its own Social Medicine Research Unit at the Middlesex Hospital, where Jerry Morris started research on the aetiology of cardiovascular disease, comparing, for example, sedentary London bus drivers with conductors who frequently climbed up and down the stairs of their double-deckers.56 The MRC Epidemiology

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Research Unit in South Wales increasingly studied chronic illness but had its origins in occupational research, and many of its members maintained socialist leanings.57 Even a study investigating chronic disease among civil servants in Whitehall led to work that identified inequality as one of the main underlying causes of ill health.58

Conclusion: chronic illness in a postmodern age Since the 1960s, Western attitudes towards modern medicine have become increasingly divided. With a generation reaching adulthood, which grew up during decades of increasing post-war affluence and without ever experiencing tuberculosis or other comparable threats to public (and individual) health, the memory of how terrible diabetes, polio, or kidney failure could be was fading, and along with it, ironically, the belief in the transformative powers of medical progress. Its benefits were taken for granted by a generation that was increasingly unwilling to follow authorities, including the medical profession. While there was still the expectation that science should find a cure for cancer, for example, this was accompanied by growing unease about how interventionist modern medicine had become and about how unnatural it had rendered the experience of normal human processes, including birth and death. With a new focus on patients and the quality of care (both curative and palliative), illness experiences have become an important topic in recent years in scholarly and biographical literature, but also in the wider world of newspaper columns and internet blogs, inviting comparisons with nineteenth-century accounts of consumptive lives and deaths.59 While Susan Sontag in 1978 dealt with her own breast cancer by analysing the writings of other authors, historical and contemporary, more recently authors such as the American sociologist Arthur Frank and the British philosopher Havi Carel have turned their own response to illness into the object of their analysis.60 Frank adopted and applied a set of ideas developed by Arthur Kleinman, who in the late 1980s focused on individual narratives to recover the hidden meanings of chronic illness, rooted in biographies and ignored by medical practitioners who had been ‘trained to think of “real” disease entities, with natural histories and precise outcomes, [and] find chronic illness messy and threatening’.61 Carel combines insightful reflections on the social world of chronic illness, and the disabling reality of living with it, with proposals for a phenomenology of illness. Accounts such as Frank’s and Carel’s are informed by a large (and growing) literature in the social sciences dealing with the embodied nature of all experience and a growing interest in the medical humanities. Illness, Frank argues, is a very particular experience. Echoing the concerns of Dubos and Dubos with regard to Victorian writings on consumption, he admits that when reflecting on illness and the changes in outlook it brings with it, there always is a danger of romanticizing the experience. Sontag herself, in fact, has become the subject of an illness memoir written by her

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son, which has been somewhat controversial as she herself never publicly reflected on her own illness.62 Some commentators have dismissed the recent proliferation of cancer memoirs as an expression of sentimentality, but even cultural historians trained to steer clear of essentialism may do well to recognize that those facing the inevitable reality of death have tended to look at life differently, searching for meanings and aspects of their biographies addressing the ‘why me’ question, be this in the Victorian period or the early twenty-first century. Historians should not shy away from these difficult issues, linking the history of medicine to the cultural history of death.63 What does the future hold? ‘Demography is destiny’, suggest the authors of a recent article in the Milbank Quarterly on what ageing baby boomers may mean for Western societies.64 An editorial in the Journal of the American Medical Association argues that we find ourselves in the fifth phase of an epidemiologic transition: the ‘age of obesity and inactivity’.65 Approaches to chronic disease have often been informed by ideas about epidemiologic transitions, based more or less loosely on the 1971 article by Omran, which has become a citation classic.66 Omran suggested that epidemiologic transitions ran through three stages: an age of pestilence and famine, an age of receding pandemics, and finally an age of degenerative and man-made diseases. His article has contributed to the misguided notion that chronic disease has only become a problem in the twentieth century—a notion that I have addressed in this chapter. Others have added to Omran’s theory by extrapolating the implicit progress narrative. In the mid-1980s a fourth stage was proposed, the ‘age of delayed degenerative diseases’: due to the development of new drugs and diagnostic methods, it was argued, medicine had increasing success in slowing the rate of chronic disease and further postponing deaths.67 In the ‘age of obesity and inactivity’, finally, we are told, the fruits of this progress are now threatened.68 In my subheadings I have proposed my own, somewhat different and incomplete periodization, emphasizing the continuities obscured by historical change. Never mind progress, chronic illness in the early twenty-first century is still linked to individual biographies and constitutions, and blamed on behaviours associated with civilization. Like consumption in the nineteenth century, however, it increasingly may affect the young again, not only the ever older. In order to arrive at a more nuanced picture of such continuities and change, we need more histories that contrast and challenge the statistics-driven master narrative behind the theory of epidemiologic transition: exemplary stories that force us to look more closely at what lies behind the figures are what historians do particularly well. In addition, we need not only comparative accounts to balance the dominance of the American case in the historiography, but also histories of chronic illness in the developing world.

Notes 1. Charles E. Rosenberg, ‘Cholera in Nineteenth-Century Europe: A Tool for Social and Economic Analysis’, in Charles E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press, 1992), 109–121.

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2. Recent examples include Mark Jackson, Asthma: The Biography (Oxford: Oxford University Press, 2009); Robert Tattersall, Diabetes: The Biography (Oxford: Oxford University Press, 2009); Steven J. Peitzmann, Dropsy, Dialysis, Transplant: A Short History of Failing Kidneys (Baltimore: Johns Hopkins University Press, 2007). 3. Arthur Kleinman, The Illness Narratives: Suffering, Healing and the Human Condition (New York: Basic Books, 1988), 3. 4. Jason Szabo, Incurable and Intolerable: Chronic Disease and Slow Death in NineteenthCentury France (New Brunswick, NJ: Rutgers University Press, 2009). 5. On mental illness, see Chapter 29 by Rhodri Hayward in this volume. 6. Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962); Margaret Pelling, Cholera, Fever and English Medicine, 1825–1865 (Oxford: Oxford University Press, 1978); John V. Pickstone, ‘Ferriar’s Fever to Kay’s Cholera: Disease and Social Structure in Cottonopolis’, History of Science, 22 (1984), 401–19; Richard J. Evans, Death in Hamburg: Society and Politics in the Cholera Years, 1830–1910 (New York: Oxford University Press, 1987). 7. Elizabeth Fee and Daniel M. Fox (eds), AIDS: The Making of a Chronic Disease (Berkeley: University of California Press, 1992). See also Chapter 7, ‘Contemporary History of Medicine and Health’ by Virginia Berridge in this volume. 8. For an excellent collection of disease biographies of a different kind, see: Barron Lerner, When Illness Goes Public: Celebrity Patients and How We Look at Medicine (Baltimore: Johns Hopkins University Press, 2006). 9. Abdel R. Omran, ‘The Epidemiologic Transition: A Theory of the Epidemiology of Population Change’, Milbank Memorial Fund Quarterly, 49 (1971), 509–38; Flurin Condrau and Michael Worboys, ‘Second Opinions: Epidemics and Infections in NineteenthCentury Britain’, Social History of Medicine, 20 (2007), 147–58. 10. Kathy Charmaz, Good Days, Bad Days: The Self in Chronic Illness and Time (New Brunswick, NJ: Rutgers University Press, 1991); Havi Carel, Illness: The Cry of the Flesh (Stocksfield: Acumen, 2008). 11. Ivan Illich, Medical Nemesis: The Expropriation of Health (New York: Pantheon Books, 1976); Brian Inglis, The Diseases of Civilisation (London: Hodder and Stoughton, 1981). 12. René Dubos, Mirage of Health: Utopias, Progress and Biological Change (New York: Harper, 1959); Szabo, Incurable and Intolerable. 13. Susan Sontag, Illness as Metaphor (New York: Farrar, Straus and Giroux, 1978). 14. René Dubos and Jean Dubos, The White Plague: Tuberculosis, Man and Society (London: Victor Gollancz, 1953). See also: Linda Bryder, Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain (Oxford: Clarendon Press, 1988); Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876–1938 (Philadelphia: University of Pennsylvania Press, 1992); Katherine Ott, Fevered Lives: Tuberculosis in American Culture since 1870 (Cambridge, MA: Harvard University Press, 1996); Sheila M. Rothman, Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History (New York: Basic Books, 1994). 15. Erwin H. Ackerknecht, ‘Diathesis: The Word and the Concept in Medical History’, Bulletin of the History of Medicine, 56 (1982), 317–25. 16. Roy Porter and G. S. Rousseau, Gout: The Patrician Malady (New Haven: Yale University Press, 1998), esp. 48–67. 17. Clark Lawlor, Consumption and Literature: The Making of the Romantic Disease (Basingstoke: Palgrave Macmillan, 2006); Carolyn A. Day, ‘Drop Dead Gorgeous: The

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18. 19. 20. 21. 22. 23.

24. 25.

26. 27. 28. 29. 30. 31. 32. 33.

34. 35. 36.

37. 38.

carsten timmermann Feminization and Idealization of Tuberculosis in England, 1780–1850’. PhD dissertation, Tulane University, 2010. Dubos and Dubos, The White Plague, 53. E. de Goncourt and J. de Goncourt, Madame Gervaisais (Paris: Librairie Internationale, 1869), quoted in Dubos and Dubos, The White Plague, 53. Basil Meyer, ‘Till Death Do Us Part: The Consumptive Victorian Heroine in Popular Romantic Fiction’, Journal of Popular Culture, 37 (2003), 287–308. Friedrich Engels, The Condition of the Working Class in England (London: Penguin, 1987), 130. M. A. Crowther, The Workhouse System: The History of an English Social Institution (London: Methuen, 1981). The Lancet Sanitary Commission for Investigating the State of the Infirmaries of Workhouses, ‘Report of the Commissioners: No. 1. Metropolitan Infirmaries’, Lancet, 86 (1865), 14–22. Ibid. 15. J. Taylor, ‘Clinical Lecture, Delivered at University College Hospital: Cancer of the Right Lung, Vertebral Column, Sterno-clavicular Articulation, Stomach and Kidneys’, Lancet, 37 (1842), 873–904. All quotes in the following paragraphs are from this article. Knud Faber, Nosography: The Evolution of Clinical Medicine in Modern Times, 2nd edn (New York: Hoeber, 1930). Jacalyn Duffin, To See With a Better Eye: A Life of R. T. H. Laennec (Princeton: Princeton University Press, 1998). Peitzmann, Dropsy, Dialysis, Transplant. Ibid. 34. N. D. Jewson, ‘The Disappearance of the Sick-Man from Medical Cosmology, 1770–1870’, Sociology, 10 (1976), 225–44. Peitzmann, Dropsy, Dialysis, Transplant, 34. Tattersall, Diabetes; Chris Feudtner, Bitter Sweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: University of North Carolina Press, 2003). For other examples of disease identities transformed by new technologies, see: Keith Wailoo, Drawing Blood: Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1997); Helen Valier and Roberta Bivins, ‘Organization, Ethnicity and the British National Health Service’, in Jennifer Stanton (ed.), Innovations in Health and Medicine: Diffusion and Resistance in the Twentieth Century (London: Routledge, 2002), 37–64. Peitzman, Dropsy, Dialysis, Transplant; Jennifer Stanton, ‘The Diffusion of Two Renal Dialysis Modalities in the UK, 1960s–1980s’, in eadem (ed.), Innovations, 145–68. Tattersall, Diabetes, 1. Carsten Timmermann, ‘Hexamethonium, Hypertension and Pharmaceutical Innovation: The Transformation of an Experimental Drug in Post-war Britain’, in Carsten Timmermann and Julie Anderson (eds), Devices and Designs: Medical Technologies in Historical Perspective (Basingstoke: Palgrave, 2006), 156–74. Jeremy A. Greene, Prescribing by Numbers: Drugs and the Definition of Disease (Baltimore: Johns Hopkins University Press, 2007). Viviane Quirke, ‘From Evidence to Market: Alfred Spinks’s 1953 Survey of New Fields for Pharmacological Research, and the Origins of ICI’s Cardiovascular Programme’, in Virginia Berridge and Kelly Loughlin (eds), Medicine, the Market and the Mass Media: Producing Health in the Twentieth Century (London: Routledge, 2005), 146–71.

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39. Christoph Gradmann, ‘Robert Koch and the Pressures of Scientific Research: Tuberculosis and Tuberculin’, Medical History, 45 (2001), 1–32. 40. Thomas McKeown, The Role of Medicine: Dream, Mirage or Nemesis? (London: Nuffield Provincial Hospitals Trust, 1976). 41. Julie Anderson, Francis Neary, and John V. Pickstone, Surgeons, Manufacturers and Patients: A Transatlantic History of Total Hip Replacement (Basingstoke: Palgrave Macmillan, 2007). 42. Royal College of Physicians, Smoking and Health (London: Pitman, 1962), 15. 43. William G. Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution (Rochester: University of Rochester Press, 2003); Virginia Berridge, Marketing Health: Smoking and the Discourse of Public Health in Britain, 1945–2000 (Oxford: Oxford University Press, 2007). 44. Gerald N. Grob, The Deadly Truth: A History of Disease in America (Cambridge, MA: Harvard University Press, 2002). 45. George H. Bigelow and Herbert L. Lombard, Cancer and Other Chronic Diseases in Massachusetts (Boston: Houghton Mifflin, 1933). 46. Jane Pacht Brickman, ‘Ernst P. Boas (1891–1955)’, Journal of Public Health Policy, 20 (1999), 348–55. 47. Ernst P. Boas, The Unseen Plague: Chronic Disease (New York: Augustin, 1940), 4. 48. Grob, The Deadly Truth. 49. Dean W. Roberts, ‘The Commission on Chronic Illness’, Public Health Reports, 69 (1954), 295–9; Commission on Chronic Illness, Chronic Illness in the United States (Cambridge, MA: Harvard University Press, for The Commonwealth Fund, 1957). 50. Joseph E. Moore and David Seegal, ‘Announcement: The Journal of Chronic Diseases’, Journal of Chronic Diseases, 1 (1955), 1–11, at 1. 51. Gerald M. Oppenheimer, ‘Becoming the Framingham Study, 1947–1950’, American Journal of Public Health, 95 (2005), 602–10. 52. Robert A. Aronowitz, Making Sense of Illness: Science, Society, and Disease (Cambridge: Cambridge University Press, 1998). 53. C.A. Boucher, Survey of Services Available to the Chronic Sick and Elderly 1954–1955 (London: HMSO, 1957). 54. M. J. Denham, ‘Lord Amulree: An Appreciation’, Age and Ageing, 34 (2005), 529–31. See also Chapter 19, ‘Medicine and Old Age’ by Susannah Ottaway in this volume. 55. S. A. Lock, L. A. Reynolds, and E. M. Tansey (eds), Ashes to Ashes: The History of Smoking and Health (Amsterdam/Atlanta: Rodopi, 1998). 56. Shaun Murphy, ‘The Early Days of the MRC Social Medicine Research Unit’, Social History of Medicine, 12 (1999), 389–406. 57. A. R. Ness, L. A. Reynolds, and E. M. Tansey (eds), Population-Based Research in South Wales: The MRC Pneumoconiosis Research Unit and the MRC Epidemiology Unit (London: Wellcome Trust Centre for the History of Medicine at UCL, 2002). 58. Michael Marmot, Status Syndrome: How Your Social Standing Directly Affects Your Health and Life Expectancy (London: Bloomsbury, 2004). 59. Carsten Timmermann and Elizabeth Toon (eds), Patients and Pathways: Cancer Experiences in Historical and Sociological Perspective (Basingstoke: Palgrave Macmillan, 2011). 60. Arthur W. Frank, At the Will of the Body: Reflections on Illness (Boston: Houghton Mifflin, 1991); idem, The Wounded Storyteller: Body, Illness, and Ethics (Chicago: University of Chicago Press, 1995); Carel, Illness.

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61. Kleinman, The Illness Narratives, 17. 62. David Rieff, Swimming in a Sea of Death: A Son’s Memoir (New York: Simon and Schuster, 2008). 63. Philippe Ariès, The Hour of Our Death (New York: Alfred A. Knopf, 1981). 64. S. Jay Olshansky et al., ‘Aging in America in the Twenty-First Century: Demographic Forecasts from the MacArthur Foundation Research Network on an Aging Society’, Milbank Quarterly, 87 (2009), 842–62. 65. J. Michael Gaziano, ‘Fifth Phase of the Epidemiologic Transition: The Age of Obesity and Inactivity’, Journal of the American Medical Association, 303 (2010), 275–6. 66. Omran, ‘The Epidemiologic Transition’; George Weisz and Jesse Olszynko-Gryn, ‘The Theory of Epidemiologic Transition: the Origins of a Citation Classic’, Journal of the History of Medicine and Allied Sciences, 65 (2009), 287–326. See also Chapter 21 by Graham Mooney in this volume. 67. S. Jay Olshansky and A. Brian Ault, ‘The Fourth Stage of the Epidemiologic Transition: The Age of Delayed Degenerative Diseases’, Milbank Quarterly, 64 (1986), 355–91. 68. Gaziano, ‘Fifth Phase’.

Select Bibliography Aronowitz, Robert A., Making Sense of Illness: Science, Society, and Disease (Cambridge: Cambridge University Press, 1998). Charmaz, Kathy, Good Days, Bad Days: The Self in Chronic Illness and Time (New Brunswick, NJ: Rutgers University Press, 1991). Dubos, René, and Jean Dubos, The White Plague: Tuberculosis, Man and Society (London: Victor Gollancz, 1953). Kleinman, Arthur. The Illness Narratives: Suffering, Healing and the Human Condition (New York: Basic Books, 1988). Peitzmann, Steven J., Dropsy, Dialysis, Transplant: A Short History of Failing Kidneys (Baltimore: Johns Hopkins University Press, 2007). Porter, Roy, and G. S. Rousseau, Gout: the Patrician Malady (New Haven: Yale University Press, 1998). Rothstein, William G., Public Health and the Risk Factor: A History of an Uneven Medical Revolution (Rochester, NY: University of Rochester Press, 2003). Szabo, Jason, Incurable and Intolerable: Chronic Disease and Slow Death in NineteenthCentury France (New Brunswick, NJ: Rutgers University Press, 2009). Tattersall, Robert, Diabetes: The Biography (Oxford: Oxford University Press, 2009).

chapter 23

pu blic h e a lth c hristopher h amlin

The great debate in the history of public health is what public health is and should be. The greatest obstacle that the historian of public health faces is getting past the implicit equation of ‘public health’ with optimal moral goodness. Unlike terms such as ‘psychiatry’ or even ‘clinical encounter’, ‘public health’ remains warm, fuzzy, and positive. Any historian of public health first confronts the problem of definition—health that is truly public. For the history of public health is not merely concerned with change of content, but also with inchoateness of concept. A tidy retrospective definition—such as response to epidemics—will fail to reflect the variety of institutions that have been concerned with the health of various publics. Some scholars will even begin with an expansive and ideal concept of health, which can serve as an analytical tool to evaluate public health as it has been and as it is. History is frequently deployed in the shaping of public health institutions. As such, public health history has often been a form of social criticism. One recognizes ways in which a society has not facilitated health and explores how it might better do so. There are no a priori boundaries to the changes that might be promulgated in pursuit of health; hence public health and its history are inextricably entangled with political philosophy and practice. Even when historians are addressing themselves to colleagues, usually there is a secondary audience and an ulterior set of contemporary and eternal issues. In three specific respects, the project of bettering the public’s health draws on history. First, the evaluation of health status is itself an historical problem: the effects of pathological or prophylactic influences on populations can only be measured over spans of time. Historians are attuned to the changing loci and labels of diseases and to the uneven adequacy of epidemiological data. As do statisticians, historians function as metaepidemiologists in assessing the impact of public health policies. Secondly, the emplacement of public health programmes is usually a slow matter and a conflictual and complicated one, involving social, cultural, political, legal, and financial factors as well as technical expertise. As health improvement programmes are repeated in polity after polity, similar problems may be re-encountered in novel contexts. Historians act as analysts of the process. Their insights can elucidate forms and causes of conflict, allowing more satisfactory

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policy. Finally, public health is an important, if under-recognized, element of the great moral dramas of history—the struggle of peoples for better lives. Often, health inequalities manifest broader inequality: those who are the focus of public health are marginalized and disenfranchised as well as unhealthy. But the main objects of public health practice are not always its primary beneficiaries. Defined in infectious, behavioural, or genetic terms, the poor may be deemed simply a class ‘dangerous’ for others. The sources of suboptimal health are many, yet to define optimality in any terms other than relation to a statistical mean requires some definition of legitimate health goods. It is difficult to talk about a healthy population without implicating general issues of happiness, prosperity, and self-determination. Questions of what kinds of levelling up can and should occur are tied to questions of legitimate aspiration, or ‘conditional citizenship’, in Dorothy Porter’s words. In some ways, to speak of public health ‘reformers’ approaches redundancy; after all, one rarely hears of public health ‘reactionaries’. Yet expectations have differed for persons of different ages, sexes, races, and classes, and in different places. Philosophies of public health vary greatly. On one side are those like Richard Epstein who would restrict public health to the control of infectious disease: applied elsewhere it is regarded as unduly redistributive and intrudes on freedom. On the other side are epidemiologists like Richard Wilkinson and Ichiro Kawachi, who recognize perceived inequalities within a society as a great (perhaps the greatest) determinant of mortality differentials. Their disagreement reflects the composite character of modern ‘public health’. It combines three distinct projects or responsibilities. First and most familiar is epidemic response, those institutions by which states act swiftly to interrupt disease transmission or generation. Second is communal medical police, including regulations for the disposal of human or animal wastes and dead bodies and for ensuring the safety of articles of commerce, ranging from fish to prostitutes, and often including the quality of medicines and medical care. Third is the overtly utopian goal of improving the human condition. During the nineteenth century, governments in industrializing (and, increasingly, democratic) nations would recognize some major domains of accountability to better the lives of their citizens. Aided by descriptive statistics, they would also discover where the human-based machine of state was performing poorly. During the twentieth century, this effort would be facilitated by the emergence of analytical statistics, the power of which could disclose the relative strengths of pathological and prophylactic factors. In the very sense of being ‘public’, public health has always been political. The very term we use incorporates a rejection of earlier institutions and terms. ‘Public health’ has at times been ‘medical police’,‘state medicine’,‘public hygiene’ (hygiène publique), or, most comprehensively, ‘social medicine’, in which our ‘public health’ was only one division. A broader ‘population health’ has recently emerged. Keeping track of these changes of terms and domains is an important task; so too is the recognition of how an apparently inclusive term might be captured by a profession or an ideology. Thus, ‘public health’ has sometimes implied ‘sanitation’, or the science of epidemiology, or institutions for regulating persons and industries.

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Practitioners’ histories: a public health of visions and revolutions Until relatively recently public health history belonged primarily to domains of public health practice and policy: practitioners used historical narratives to justify their approaches. Consider, for example, English Sanitary Institutions (1890) by John Simon (1816–1904), Britain’s first Chief Medical Officer from 1858 to 1876. In his first 150 pages, Simon speculated about the early creation of sanitary communities, devoting much space to medieval philanthropy. Finally, in a chapter entitled ‘The Growth of Humanity in British Politics’, he presented public health as a generic liberal institution, along with democracy and the abolition of slavery. However, in the bulk of the book, the ageing Simon used this glorious foundation to settle old scores, to make the case for an independent medical role in English social policy, the matter over which he had resigned from public service in 1876. Likewise, Sidney and Beatrice Webb’s The State and the Doctor (1910) was less a comprehensive history than a series of focused analytical essays on administrative achievements or errors. Experience of health and disease too was swallowed up in larger narratives. For Seebohm Rowntree (1871–1954), health status was a measure, and secondarily a cause, of poverty; and Karl Marx (1818–83) had used public health reports to chronicle the systematic destruction of bodies in the creation of surplus value, without seeing the issue in terms of health. The revolution in science-based public health does not loom large in such works, although these authors were writing at a time when the union of epidemiology and bacteriology was disclosing the necessary cause and route of transmission of one acute infectious disease after another, and Simon himself was instrumental in initiating the commitment of public funds to medical research. Some then, and some historians later, have seen an essential tension between an ‘old’ public health, which promoted moral and environmental reforms that were collectively to augment health in general, and a ‘new’ science-based public health, which would operate disease by disease, and seek to disrupt some vulnerable part of the causal chain of disease production. This supposed paradigm shift would be part of what is sometimes presented as a stadial history of public health: a moral stage (disease from sin) was successively followed by an environmental stage (disease from filth), and an agent-based germ theoretic stage (in which disease was due to one’s accidental status as culture medium or, perhaps, as gene carrier). Latetwentieth-century versions might add a stochastic stage, in which disease is the probabilistic product of multiple risk factors with varying degrees of avoidability. As Louis Pasteur (1822–96) and Robert Koch (1843–1910) were becoming household names, a historiographical genre of heroic medical scientists and activists was developing. Prefigured by the cult of Edward Jenner (1749–1823), it would be exemplified in the titles of popular works by the American bacteriologist-turned-science writer Paul de Kruif, in Microbe Hunters (1926) and Men against Death (1932). The distinction between a broadly based health promotion approach and one focused on specific

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disease prevention remains a sensitive one in contemporary policy and in historiography, but there is less tension in these early works than one might expect. The Pasteurian tradition included environmental factors, while Koch’s legacy, as Richard Evans has shown, was remarkably flexible: the Prussian conservative would become a worker’s hero. At the same time, the statism of authors like Simon and the Webbs presumed that administration would be founded on rationality and thus on the most modern science. A reciprocity operated. Scientific breakthroughs underwrote utopian confidence in a coming age of health, while the rising tide of social and political progress translated into the acceptance of ever more aggressive germ theoretic interventions and research support. Such eclecticism is evident, for example, in George Rosen’s synthetic A History of Public Health, published in 1958. Elizabeth Fee notes that Rosen sought to balance criticism of the social production of disease with inspiration of those fighting those problems, whatever their means. In The Conquest of Epidemic Disease (1943), C.-E. A. Winslow told the history of public health in terms of the familiar Comteian chronicle of superstition yielding to science, with bacteriology as apotheosis, but in his own career as founder of the Yale School of Public Health, Winslow was part of a multifaceted reformist approach. The deepest exploration of these issues was a novel, Arrowsmith, published in 1925 and the product of collaboration between Sinclair Lewis and Paul de Kruif. Its recognition of moral ambivalence in public health was decades ahead of its time. As assistant health officer in Nautilis, Iowa, young Dr. Arrowsmith wishes to replace the sloganeering of his superior with a public health based in serology, bacteriology, and epidemiology. But the public rejects effectiveness, Arrowsmith is forced out, and public health reverts to huckstering. Later in the novel, Arrowsmith encounters the ethical dilemmas of the new science-based public health. To carry out a controlled trial of a phage treatment for plague on a Caribbean island he withholds the treatment from part of a plantation population of poor blacks, who are volunteered for that fate by an enlightened planter, acting against the sensibilities of colonial officials, who find the protocol inhumane. The episode foreshadows the Tuskegee syphilis trials that would begin within the decade and echoes modes of vaccine-testing taking place around the world. Other characters, like the misanthropic German immunologist Max Gottlieb and the globetrotting rat-catcher Gustaf Sondelius, embody approaches to public health and types of professionalism that may still be recognized. Lewis and de Kruif contrasted administrative and political incoherence with scientific power and visionary expectations. They also recognized the multiple sources of ambivalence—not only from ordinary folk going about their lives, but also from doctors, who were deeply suspicious of the encroachment of public medicine on the medical marketplace. This last matter of an essential tension between public health and clinical medicine has been especially acute in the USA, where programmes of social insurance have had so little traction. In much of the Europeanizing world, a different form of public health history was taking shape, one more confident in an expanded conception of public medicine. Hippocrates, early-nineteenth-century French hygienists, and Rudolph Virchow’s investigations of the 1847 Silesian typhus epidemic could supply theorists like Alfred Grotjahn (1869–1931) in Germany and John Ryle (1889–1950) in England

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with a medical heritage for their work, but they relied more on the emerging social sciences. An exemplar of the genre is The Advance to Social Medicine (1952), a historical work by the Belgian social medicine scholar René Sand (1877–1953). In Sand’s powerful first five pages, medicine is presented as a primary social force. It works in conjunction with the ‘efforts of the masses themselves’ to combat ignorance and poverty, and rests on advances in agriculture and in other forms of wealth-producing technology that provide the surplus for achievement of universal health. The historical architectonic, however, was not science but solidarity: the social-medical insurance that European states had come to supply was the outgrowth of informal institutions of mutual assistance. As health-accountability spread to factories and schools, a tipping point was reached. Bacteriological discoveries had allowed ‘the medical practitioner himself [to become] an instrument of public health’, Sand observed without irony. However, more important were housing and nutrition programmes, public health nurses and psychiatric rehabilitation, child development, and care institutions for the elderly. For Sand, health inequalities were not merely facts but problems, and his vision was unapologetically technocratic: social medicine joins forces with the school of thought, taking shape at the same period, which aims at rationalizing not only production but all human activities . . . It is in order to protect man, to cultivate his mental and spiritual gifts, to encourage that expansion of his personality on which individual happiness and social equilibrium alike depend, that medicine joins forces with this ‘human economics’, adopts its point of view and embraces man as a whole—in the cradle, at school, at work, and in the home.12

Sand’s vision was also statist; in Britain, such perspectives were often communitarian, but no less comprehensive. Sand was activist first, historian second. In America, a group of left-leaning émigré medical historians—particularly Henry Sigerist (1891–1957) and Erwin Ackerknecht (1906–88), and their American but German-trained colleague George Rosen (1910–77), would represent such perspectives as historians more than as practitioners or activists. In 1941, Sigerist, editor of the Bulletin of the History of Medicine, printed a translation of Johann Peter Frank’s inaugural 1790 lecture on ‘the People’s Misery as Cause of Disease’. Frank had been the most conspicuous founder of the medical police movement; he sought to expand the medical domain to comprehend all the ways in which the state might augment health and thereby happiness. Though the making available of an important text was a more conspicuous part of the history of medicine then than now, that the canonicity of Frank’s text seemed self-evident to Sigerist speaks volumes. Four years earlier, Sigerist had published a glowing assessment of public health under Lenin and Stalin. There he compared a private and individualist approach to health to a cancer in the body: ‘The more specialized, the more differentiated a society becomes, the more the individual members have to give up liberties and assume many duties toward society. We are obliged to send our children to school and have them vaccinated whether we like it or not.’

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christopher hamlin

Ackerknecht in turn would be responsible for bringing the foundational social medical work of Rudolph Virchow (1821–1902) to the attention of English-speaking historians. Sent to study the typhus epidemic in Silesia in 1847, Virchow and Sebastian Neumann attributed it to the miserable social conditions of the population, which they further attributed to quasi-feudal policies. This episode was seminal in Ackerknecht’s doctoral dissertation and later for pioneers in the Society for the Social History of Medicine in the early 1980s. But Virchow’s entire career was exemplary: a convergence of social epidemiology, positivist science, institution building, and political activism (within a constitutional context). Ackerknecht found many of the same themes in the Paris clinicians and hygienists. If, as Ann LaBerge and William Coleman would later point out, the hygienists were ambivalent towards intervention in the political economy of health, they nevertheless saw health in terms of social conditions. Like Virchow, their radicalism was fixed in pathology: stark empiricism and not sentimental malarky was the true basis for reform. In the twentieth century, too, social medicine would be tied tightly to social science. Social inquiry itself was a component of, perhaps tantamount to, social progress. Following a thesis on the health of miners, Rosen too explored the heritage of Virchow in his seminal 1947 essay ‘What is Social Medicine?’. There he folded a wide range of European authors into what was in its mature form an arm of early-twentieth-century German social thought. This was the forerunner of a series of essays on antecedents of this social medicine, mainly in central Europe, from the early modern period through the eighteenth century. However, Rosen’s appraisal was ambivalent and he was among the first to uncover tensions that would loom large a generation later. Hapsburg medical statecraft was enlightened to be sure, but absolutist too. A public health not grounded in liberal values, concerned more with states than with persons, was ultimately inadequate. Overall, one is struck by the optimism of these scholars. Probably more than other historians of medicine, historians of public health are used to admiring their subjects, who are not in it for the money and whose efforts are so often stymied by those who are. But even among public health historians, these writers often used a utopian measuring stick. Their optimism reflected their focus on philosophies of health.

Public health and critical social history Looking down from eminent positions within the medical world, these early scholars missed much that historians and others—social scientists, theorists, and critics, of many stripes—would pick up on in succeeding decades. Often they had little sympathy with the complexities of application, the work of those many front-line practitioners of public health. Not only were these executing minions overlooked, but often they were also regarded as impediments—lazy, stupid, corrupt, or simply set in their ways: for them, public health was a matter of principles, not practice.

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Even more brazen was the invisibility of the great public of public health. There was attention to class at least in a general way, and sometimes to life stage, but rarely to culture, gender, or race. Since the primary factors affecting access to health were presumptively economic, these should not matter, and since they should not, many assumed that they had not. One result was obliviousness to the centrality of eugenics in many systems of social medicine. Another was naïvety to colonial contexts. The schemes of social medicine were hatched in terms of class and more particularly labour relations in industrializing nations, in a domain of political struggle for (mostly male) workers’ rights. With the aid of experts, institutions, and infrastructure, appropriate citizenly status might be more fully realized. However, many indigenous or rural people encountered public health mainly as imposition (for example, mandatory vaccination) or as restriction of trade or movement. Further, the workers in question were in the first instance men. Women were only relevant with regard to reproductive health matters or as carriers of venereal infections. In brief, between the history of social medicine and the social history of medicine, there turned out to be a great gulf. A vision of progress and a concern with justice both continue to underlie much work in public health history, yet usually they are implicit and under-defined: ‘utopian’ retains disturbing resonances and concerns are expressed piecemeal and often incoherently. Few want to wrestle with the touchy problem of what human health and well-being should be or of what comprehensive institutions of health preservation should lie behind correction of all the singular outrages. When social medicine resurfaced as a subject of historical research in the 1980s, it did so in a climate of nostalgia: why had the golden hopes not been realized? Schemes of social medicine had either receded or had been mangled in post-war bureaucracies. Public health had been overtaken by another historical motif, the growth of the welfare state—democratic, egalitarian, responsive, and protective. Statism, particularly Benthamite statism, had a remarkable appeal in the 1950s and 1960s as many historians recognized their post-war present as an extension of Victorian achievement. The problems of urban health that had arisen during the Industrial Revolution had been tackled with commendable energy in the decades prior to the First World War. Interest in public health emerged at the confluence of two related historical questions, which, with some additions, continue to frame much public health history—and not just in Britain. The first was related to the ‘revolution in government’ question. At the beginning of the nineteenth century, Britain had a minimal central government. A sense of state responsibility for health was limited to occasional invasions of plague. To many liberal ideologues and radical journalists, the British state was already top-heavy with placemen and pensioners. Yet a century later Britain was a model bureaucratic state, a land of inspectors and clerks. Press and parliament enforced remarkable accountability; civil service reform and professionalization brought competence; and the system of blue books—the exhaustive investigations of select committees, royal commissions, and civil administrators—exemplified responsiveness and transparency. Prodigious improvements in sanitary infrastructure, analytical monitoring of causes of death, and a ready, coordinated, national response to epidemics was the result. After 1911, much of this

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would be organized by a Ministry of Health, though health was important in other ministries too. The upshot is that even amidst the welter of form-filling and by-law following, there is no real English equivalent to Joseph K’s experience in Kafka’s Castle. Liberalism had evolved towards fair and efficient service delivery; the mediating voice of bureaucracy was equally that of reason and of progress. Second was the ‘standard of living question’, an offshoot of the new social history (or history from below, as it was known). Had the new capitalism diminished human wellbeing or augmented it, and, if the latter, how quickly had its growing pains been overcome? How should health and disease be included in this measure? It might be argued that differential disease experience was a function of differential exposure, resistance, and access to care, and thus a central component of standard of living, or, equally, that infectious epidemics were aberrant events, noise distorting any signal linking social or economic condition to life-course. These matters would be explored by an increasingly interdisciplinary community composed not only of those who would earlier have seen themselves as historians of public health, but also including social historians, demographers, and geographers: Anne Hardy, Bill Luckin, Graham Mooney, and Simon Szreter and others in the Cambridge history of populations group. But another kind of social history was qualitative. Class relations were matters of perceptions of self and others, not just of wages or death rates. To the Hammonds, to E. P. Thompson, and to a generation of social historians studying the late eighteenth through to the mid-twentieth century, health was but one component of perceived social condition. Usually it was a minor component, under-appreciated both by historians and by their subjects. Behind the assessment of social condition was the revolution that never came; a key question was why, among a literate, critical, and intelligent proletariat, misery and injustice (including disease) had not generated stronger demands for change. Recognition of social condition as a political matter, however, had the effect of blurring the boundaries of health. Ultimately, the social historians’ view would merge with the views of the pioneers of social medicine, but that did not happen quickly or smoothly. Neither the inquiry into the revolution of government nor the determination of changes in the standard of living was solely an empirical question. Both were founded in a deep distrust of the health effects of laissez-faire and a corresponding faith in just, democratic, and expert states. Thus the revolution in government was seen as the triumph of the national state in which political philosophy, embodied equally in a ruling party and in an apolitical professional inspectorate, could overcome slum lords and shopowner-dominated town councils. Even more direct was the indictment sought by standard-of-living critics, who were seeking redress not only for the injustices of the industrial capitalists, but also for the enclosing landlords who had broken the Tudor social contract to take over social provision from the eliminated monasteries. At the junction of these distinct but complementary inquiries was the enigmatic figure of Edwin Chadwick (1800–90) and the cult of sanitation. The appearance in the early 1950s of two magisterial biographies, one focusing on the entire career, the other on his public health achievements, resurrected the reputation of Chadwick, who had been passed over in the enthusiasm for state or social medicine. As finder of facts, legislative

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draughtsman, and browbeater of doubters, Chadwick represented also the responsiveness of the state in exposing the grimmest social realities and in taking hard and costly steps to address them. That Chadwick was reviled as architect of the hated new Poor Law, had exonerated employers of child labour from the charge of systematic manufacture of debility, and had denied that poverty harmed health, did not register: he was responsible for the first great law requiring the retrofitting of towns in the name of health, the Public Health Act of 1848. When it came to sanitation, E. P. Thompson, usually distrustful of bureaucratic reformers and their blue books, lost his edge. So too, the Hammonds had made Chadwick and company the deliverers of Chartism. For public health history, the implications of the imposition of the Chadwickian template were enormous. First, it represented a de-medicalizing of public health. The old view of an eternal and essential opposition between cure and prevention became central: the barrister Chadwick had notoriously bad relations even with sympathetic physicians. Secondly, it put a premium on statistics. Primarily, these were descriptive; analytical statistics came only with the Pearsonian revolution, which began late in the century. Often Victorian sanitary statistics were sensation parading as empiricism. Facts were marshalled action, although frequently they did not. The French hygienist-epidemiologists, who had been equally fact-hungry a generation earlier, had had no such expectations; their lack of engagement would become an aberration to be explained away. Thirdly, the Chadwickian template placed great value on comprehensiveness and centralization. Bypassing the Webbs’ studies of the remarkable achievements of local governments, Chadwickian historians represented local initiatives as a pale version of what the robust state could do. This view carried over to other lands. But, for the Marine Hospital Service and the short-lived National Board of Health of the mid-1880s, American public health was a woeful record of state or municipal corruption and incompetence. Similarly, public health came only with German unification—Max von Pettenkoffer’s inspiring decades-long commitment to Munich’s hygienic evolution was no match for Koch’s imperial fiat. Fourthly, it equated public health with sanitation, and thus with infrastructure—with water and sewerage works, straight and paved streets, and finally ventilated and heated housing. Correspondingly, it put a premium on the ‘filth’ diseases that better sewers and water might presumably put right. John Duffy’s 1990 history of American public health would be titled The Sanitarians. This orientation towards sanitation, which was England’s forte or obsession (depending on the commentator), served further to Anglicize public health; elsewhere public health efforts were often oriented more to surveillance, isolation, and medical provision. The sanitarian focus dovetailed nicely with the emerging status of cholera as exemplary public health problem. In terms of enormity—extent, horrific symptoms, and the extremity of the penitential preventives—it had displaced plague; indeed, Michael Durey’s path-breaking 1979 book on cholera was entitled The Return of the Plague. Apparently newly global, cholera had been a ‘shock disease’. Cholera-induced panic was presumed to represent a stress test of class relations and social solidarity; it might even trigger metamorphosis into some new social phase, whether revolutionary or reformist. The home ground of John Snow’s epidemiology and the locus of a major discovery

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by Robert Koch, cholera served also as a means for reintegrating narratives of science and state-building. Again, the implications were profound. From the late 1950s through the early 1980s, the cholera fixation pushed out of the picture other epidemic diseases of great demographic import: typhus, smallpox, yellow fever, influenza, and even malaria and tuberculosis (‘captain of the men of death’). Almost entirely lost sight of were endemic infectious diseases, chronic non-infectious diseases, debilities caused by hunger and poor diet, cold and exhausting work, and the multiple sources of accidents and neglect. From such a standpoint, public health did not apply to the miserable normal (which, perhaps by definition, could not be pathological), but only to crises. Even the eventual supercession of sanitation-centred public health history, manifest as a return to a now scientized medicine, did not wholly shift the expectation that public health was a problem of legislation, more than one of practices—whether of public health workers or of those with, or on, whom they worked. Only in the late 1970s did public health, like many other domains of history of medicine, became the focus of social (and sometimes, cultural) historians. Suddenly, it became clear how far-reaching had been the virtual exclusion of sick persons from the dominant stories of public health. They had generally been present only as cellar-huddling Dickensian masses, artefacts of the eyes (and noses) of reformers, and registered as appalling rates of mortality. It is striking to realize how revolutionary was F. B. Smith’s The People’s Health, 1830–1910 (1979), a work that succinctly fulfilled its title. While a few earlier social historians, like Louis Chevalier, had been interested in the biological experience of the anonymous poor, increasingly the new interest was on mentalities, the perceptions of diseases and of health, of risk, and of quality of life. Interest in these views from below reflected the impact of the hermeneutic social sciences, including medical anthropology and feminist scholarship. The constructedness of disease and health loomed much larger; so too did the ambivalent character of public health campaigns, often reframed as ‘social control’. Though rooted in the legacies of Marx, Freud, and their followers, the main source for this perspective was the French sage Michel Foucault (1926–84), especially his The Birth of the Clinic (1963) and Discipline and Punish (1975). In the latter, Foucault explored the conjunction of education with penology, and suggested that modernity was one great public health project that transformed free persons into cogs in the great social machine. In Michael Ignatieff ’s Foucauldian study of Benthamite penology, A Just Measure of Pain (1978), the prison reformer John Howard, hitherto a hero of humanitarianism and, by association, public health, was re-treaded as a sinister manipulator of human souls. Foucault’s former work, increasingly re-read in terms of the latter, was a narrower history of the emergent power of the medical gaze, a perception of lay person by expert founded in the newly important domain of pathological anatomy during the French Revolution. With that gaze came the power of reduction and a new form of inequality. An indication of the profundity of that transformation is the changing reputation of Jeremy Bentham. To earlier historians of public health Bentham had been a prophet of progress. To post-Foucauldians, ‘Benthamite’ statism conjured images of the irresistible

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total institution. Earlier, the motives of public health had rarely been questioned. Its means might be more or less effective, but compared with fee-hungry doctors, public health workers were paragons of virtue, risking their lives in the vineyards of excrement. If the roles did not quite reverse, at least the interests of the private practitioner were transparent, unlike those of the ingratiating medical state, which invariably claimed to be one’s friend. Foucauldianism represented a far-reaching shift from Thomsonian social history. From the new perspective, things were often getting worse, not better. Hitherto the history of public health had been dominated by simple nineteenth-century dichotomies— dirty or clean, stagnation or progress. Henceforth, public health would be represented as an arena of ambiguous and multivalent enterprises. These were backed by the twin behemoths of the biological and the social sciences: disciplinary power easily became disciplining power. Much ill-health would be attributed to lifestyle; these social scientists knew how to make you change yours. In fact, there were plenty of examples of dubious public health programmes that could be alluded to. Most notorious was the Tuskegee experiment, beginning in 1932, in which the US Public Health Service sought to determine the natural history of untreated syphilis on a poor, uninformed, African-American population. Broader was the eugenics movement, increasingly recognized less as an aberration of social medicine or a perversion of public health and more as the apotheosis of both. In America, the masking of racist immigration policies under the guise of health protection became plain. Elsewhere, the appalling sexism of most venereal disease prevention policies became apparent. Focusing almost exclusively on female prostitutes, they effectively represented women as vectors, not victims. Colonial and post-colonial contexts provided ample material for a Foucauldian analysis. Hitherto public health history had focused on the developed world. As historians turned to understudied former colonies or to the states of the so-called ‘third world’, they began to emphasize how pervasively health programmes had been framed in terms of colonial agendas. In Rockefeller Medicine Men (1978), Richard Brown excoriated the Rockefeller Foundation for colluding with, and thus propping up, Latin American dictators. Later workers would go past Brown to take up the ways in which public health discourses were becoming means of hegemonic consolidation, cultural destruction, and socioeconomic marginalization. The theme of these explorations was not solidarity or progress but a contest for power over the individual. Revolution in government historians had generally celebrated the arrival of state power; the Foucauldian ‘governmentality’ resonated very differently. To the public health practitioner, ‘surveillance’ had seemed (and still does) an essential means of protecting the public from infectious disease; to the Foucauldian it was a term to cower before, the operant mode of a police state. Searching Eyes, the title of a recent history of disease surveillance, aptly catches the dominant tone. Health had an ambiguous place in this context of individual–state relations. Some works effectively championed resistance to public health. Vaccination was the exemplar. Earlier public health historians had treated it unproblematically—a great boon of

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humanity, the first effective response to a deadly disease. Yet, as states moved to institute comprehensive vaccination during the nineteenth century, a vocal minority often refused to cooperate. Their objections were various: the inferiority of vaccination programmes, distrust of public administration, denial of the state’s power over the body, and rejection of the world view that sanctioned vaccination.

Conclusion This historiography from below might express eloquently the anxieties of a newly enfranchised and upwardly mobile class, but it lacked a framework to consider the concerns of the state with its susceptible population of potential victims or carriers, or the activities of the menacing virus. Could it be that even the most free and liberal states had sometimes to act as herders of human stock? By the end of the 1980s, such concerns had re-emerged. Deadly infectious diseases, it became clear, had not been obliterated and new ones were constantly forming. Human population density, rapid transportation, and close contact with host populations of domestic animals convinced some experts that highly lethal pandemics must come sooner or later. After 2001, there was greater concern that they would come as acts of bioterrorism. But while journalists like Richard Preston and Laurie Garrett, as well as novelists and film-makers, catered to the public fascination with disaster, dwelling on the need for a coordinated, and even military response (haz-mat suit public health), historians were generally looking away from infectious disease and away from the scientific foundations of contemporary public health. Few wanted to explore the appropriateness of coercion of innocent populations, the isolation or incarceration of victims and carriers, or any kind of public health triage. Foucault wrote before the recognition of HIV/AIDS, at a time when institutions of public health in the developed world had finally taken up the problem of lifestyle-related mortality excesses as part of a broader inquiry into the prevention and control of noninfectious and chronic diseases. Such inquiries were made possible by the development of mathematical means to extract regularities from large populations and by technical achievements in computing that allowed those techniques to be readily used. The famous longitudinal study begun in the late 1940s in Framingham, Massachusetts, shed light on cholesterol-rich diets as an important risk factor in atherosclerosis; such approaches were also important in disclosing the carcinogenicity of cigarettes. The disclosure of such lifestyle-related factors, whether understood as integrative proxies (risk factors) or as specific agents, raised the question of what socioeconomic and cultural forces sustained these unhealthy behaviours. It seemed clear that in some cases—alcohol, tobacco, and junk food—unhealthy behaviours either reflected the excesses of rampant consumerism or a highly stressful environment, or both. But how to take up these common issues? Were these matters truly problems of the public, conceived as a state, of individuals, or simply conditions of populations? Health education

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had long been a component of public health, but subsidiary to the more direct work of sanitation, disinfection, vaccination, or isolation. Hygienic advice, by contrast, had been the province of the personal physician. And was the story one of research triumph, grudging enlightenment of the population, innovative policy or law, or consumer revolution? Presumably changeable lifestyle factors graded into a toxic physical and social environment that could not be so readily remedied. Beyond environmental filth and, later, microbes, lay an array of novel chemical entities, effective individually or in concert as teratogens, mutagens, or carcinogens, or, finally, as endocrine disrupters subtly altering children’s growth. Not only were the variables many, but the effects might manifest only after long periods of exposure. Certain places might be inherently toxic even if particular agents could not be isolated. The complexity of interactions undercut faith in public health authorities, as well as challenging the epidemiological science on which those authorities relied. Remarkable analytical techniques did not bring with them high levels of confidence that one was living in healthy circumstances. These events have led to a dramatic shift in public health history. Once in the unsanitary past, public health horror stories are now in the toxic present and a future of overpopulation and environmental deterioration. Reconstructors of plague or cholera epidemics had enjoyed the luxury of the armchair general in recognizing vulnerable populations, highlighting incisive preventive actions. Increasingly, it was less clear what such actions should be or should have been. ‘Public health’ no longer advanced along a single broad front. So many factors undermined health; to focus on one (like environmental carcinogens) was to ignore others (carcinogens from smoking). Such conflict might be recognized at the level of budgetary priorities or in the smoke-and-mirrors arena of industrial exculpation, but there were deeper dilemmas as well, like the incompatibility of security and freedom. Trapped in antiquated institutions, official public health programmes were often inadequate even to recognize these threats, much less to respond to them. From the new standpoint, the paternalism of an older public health history was obscene, whether in social medical or statist forms. The traditional Dickensian mode, in which public health was a form of state charity provided by knowing and wealthy avuncular authorities to the wretched in the slums, stigmatized free persons and ignored the grander structural contradictions that undermined health. Displacing it as the criterion for assessing public health programmes was a proposition that at first glance had no necessary connection to health: liberty and justice for all. A libertarian approach to health had been central to the Foucauldian critique; public health had so often been a regulator of lifestyle orthodoxy, most conspicuously in sexuality, but in every other aspect of life as well. At a generic level, critics of the ‘new’ public health (or, since the label had already been appropriated for laboratory-based public health of the late nineteenth century, the new ‘new’ public health) shared common ground with conservative critics of an expansive public health. In the view of Lupton and Petersen, ‘healthism’ was an ‘imposed’ identity, a neo-liberal conception of person as productive firm that led to ‘intolerance of those who are unable or unwilling to

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subscribe’ to that ethos. The persistence, despite health education, of ‘pleasurable or playful activities’, such as smoking, obesity, and unsafe sex, might ‘simply represent attempts to construct subjectivity through alternative practices, privileging the pleasures of smoking, for example, over its imputed long-term health effects’. Such critiques were most conspicuously successful among AIDS activists. They went far in negotiating a new contract between a community of potential victims and the regulatory and research arms of public health. Such acceptance of health self-fashioning was on the one hand historical analysis, linking resistance to the ‘Nanny state’ to earlier episodes such as vaccination resistance. Dorothy Porter ended her magisterial history of public health with precisely these issues, noting that body sculpting was a conspicuous feature of the public health of the 1990s. But it was also critique, a profound recognition that public health had not been democratic, and, perhaps, that its inherent coercion was unacceptable. The criterion of justice, defined in terms of equality, was often in tension with that of liberty, if only in the sense that one was individualistic and the other communitarian. In past centuries, public health programmes had often been disease specific, concerned only with passing epidemics. Increasingly, the tone was one of entitlement, based in equality. The post-Second World War revolutions in statistics and computing and the recognition of complex aetiologies brought much greater appreciation of fundamental health inequalities, measured in morbidity or mortality, that were distinct geographically and often racially as well. Such inequality was taken as injustice. These health metrics were the clearest witnesses, for we were all canaries in the mine. Among infectious diseases, the exemplar was the history of tuberculosis. Up to the 1990s, historians had taken little interest in tuberculosis even though it was a greater killer than cholera, then seen as the signal disease of the nineteenth century. Its narrative was as obscure as cholera’s was clear. Whether tuberculosis was a single, or a contagious, disease had not been clear; discovery of its microbe agent produced no magic bullet prior to the serendipitous discovery of antibiotics, whose control it now threatens to escape. It defied simple sanitary improvements; its variable clinical features were subject to too many factors, existing at many degrees of remove from the disease itself. It was clear that tuberculosis incidence and recovery were integrative of social and economic conditions. If it hit all classes, it hit the poor harder. They had less access to the many modalities of treatment and recuperation, and fewer means to avoid reinfection. Hence, even in the nineteenth century, it was a proxy disease, an indicator of forms of inequality that contributed to other forms of disease as well. Foucauldianism has faded. So too has the preoccupation of the 1990s with a selffashioning that seemed sometimes bent on defying biological embodiment. At the end of the first decade of the twenty-first century, there are more conspicuous examples of greater incorporation of history in public health research and practice. However, if history plays less of an oppositional, and more of a synthetic (if still critical) role than it once did, the optimal modes for its incorporation are still by no means wholly clear. The grand issues of politics, power, and possibility remain central; the prospect for policies that will improve health overall is much less sanguine than it once was.

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Notes 1. Dorothy Porter, Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times (London: Routledge, 1999), 231–77. 2. Richard Epstein, ‘Let the Shoemaker Stick to His Last: A Defense of the “Old” Public Health’, Perspectives in Biology and Medicine, 46 (2003), 138–59. This appeared in a special issue on ‘Social Determinants of Health and Disease’. 3. Ichiro Kawachi, Bruce P. Kennedy, and Richard Wilkinson (eds), The Society and Population Health Reader, vol 1: Income Inequality and Health (New York: The New Press, 1999). 4. John Simon, English Sanitary Institutions Reviewed in Their Course of Development, and in Some of the Political and Social Relations, 2nd edn (London, 1897), esp. xi. 5. Sidney and Beatrice Webb, The State and the Doctor (London: Longmans, Green, 1910). 6. B. S. Rowntree, Poverty: A Study in Town Life, 4th edn (London, 1902); Karl Marx, Capital: A Critical Analysis of Capitalist Production, trans. from the 3rd German edn by Samuel Moore and Edward Aveling, 3 vols (New York: International Publishers, 1939), I, esp. 217–65, 670–81. 7. Andrew Mendelsohn, ‘ “Typhoid Mary” Strikes Again: The Social and the Scientific in the Making of Modern Public Health’, Isis, 86 (1995), 268–77. 8. Andrew Mendelsohn, ‘ “Like All That Lives”: Biology, Medicine and Bacteria in the Age of Pasteur and Koch’, History and Philosophy of the Life Sciences, 24 (2002), 3–36; Richard J. Evans, Death in Hamburg: Society and Politics in the Cholera Years 1830–1910 (London: Penguin, 1990), 478, 507. 9. Elizabeth Fee, ‘Public Health, Past and Present: A Shared Social Vision’, in George Rosen, A History of Public Health, expanded edition (Baltimore: Johns Hopkins University Press, 1993), ix–lxvii, at x–xi. 10. C.-E. A. Winslow, The Conquest of Epidemic Disease (Madison: University of Wisconsin Press, 1980); Arthur Viseltear, ‘C.-E. A. Winslow: His Era and His Contribution to Medical Care’, in Charles Rosenberg (ed.), Healing and History: Essays for George Rosen (Folkestone: Dawson, 1979), 205–28. 11. Sinclair Lewis, Arrowsmith (New York: Harcourt Brace, 1925). 12. René Sand, The Advance of Social Medicine (London: Staples Press, 1952), 1–5. 13. Jane Lewis, What Price Community Medicine? The Philosophy, Practice, and Politics of Public Health since 1919 (Brighton: Prentice-Hall, 1986); Jane Lewis, ‘The Public’s Health: Philosophy and Practice in Britain in the Twentieth Century’, in Elizabeth Fee and Roy Acheson (eds), A History of Education in Public Health: Health That Mocks the Doctors’ Rules (New York: William Wood, 1991), 195–229. 14. Elizabeth Fee and Edward T. Morman, ‘Doing History, Making Revolution: The Aspirations of Henry E. Sigerist and George Rosen’, in Roy Porter and Dorothy Porter (eds), Doctors’ Politics, and Society: Historical Essays (Amsterdam: Rodopi, 1993), 275–311. 15. Henry Sigerist, Socialised Medicine in the Soviet Union (New York: Norton, 1937), 19; J. P. Frank, ‘Academic Address on the People’s Misery’, Bulletin of the History of Medicine, 9 (1941), 88–100. 16. Charles E. Rosenberg, ‘Erwin H. Ackerknecht, Social Medicine, and the History of Medicine’, Bulletin of the History of Medicine, 81 (2007), 511–32. 17. Erwin. H. Ackerknecht, ‘Hygiene in France, 1815–1848’, Bulletin of the History of Medicine, 22 (1948), 117–55; idem, ‘Anticontagionism between 1821 and 1867’, Bulletin

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18. 19.

20. 21. 22.

23. 24. 25. 26. 27.

28.

29.

christopher hamlin of the History of Medicine, 22 (1948), 562–93; see commentaries on ‘Anticontagionism’ by Christopher Hamlin, Charles Rosenberg, Alexandra Stern, and Howard Markel in International Journal of Epidemiology, 38(1) (2009), 22–33; Ann LaBerge, Mission and Method: The Early-Nineteenth-Century French Public Health Movement (Cambridge: Cambridge University Press, 1992); William Coleman, Death Is a Social Disease: Public Health and Political Economy in Early Industrial France (Madison: University of Wisconsin Press, 1982). George Rosen, ‘What is Social Medicine? A Genetic Analysis of the Concept’, Bulletin of the History of Medicine, 21 (1947), 674–733. Best known is a 1957 essay on the concept of medical police. These essays, and the ‘What is Social Medicine?’ essay, were reprinted in George Rosen, From Medical Police to Social Medicine: Essays on the History of Health Care (New York: Science History, 1974). See also Christopher Hamlin, ‘The Fate of the Concept of Medical Police’, Centaurus 50 (2008), 63–9. Fee, ‘Public Health, Past and Present’, xv. Ibid. xvii. Porter, Health, Civilization, and the State; Dorothy Porter, ‘The Decline of Social Medicine in Britain in the 1960s’, in eadem, Social Medicine and Medical Sociology in the Twentieth Century (Amsterdam: Rodopi, 1997), 97–119. Roy M. Macleod (ed.), Government and Expertise: Specialists, Administrators, and Professionals, 1860–1919 (Cambridge: Cambridge University Press, 1988). John Eyler, Sir Arthur Newsholme and State Medicine, 1885–1935 (Cambridge: Cambridge University Press, 1997). Arthur J. Taylor (ed.), The Standard of Living in Britain in the Industrial Revolution (London: Methuen, 1975). Andrew Appleby, Famine in Tudor and Stuart England (Stanford: Stanford University Press, 1978). Simon Szreter, Health and Wealth: Studies in History and Policy (Rochester, NY: University of Rochester Press, 2005); Anne Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856–1900 (Oxford: Clarendon Press, 1993); eadem, ‘Urban Famine or Urban Crisis? Typhus in the Victorian City’, Medical History, 32 (1988), 401–25; Robert Woods and John Woodward (eds), Urban Disease and Mortality in Nineteenth Century England (London: Palgrave Macmillan, 1984); Robert Woods and Nicola Shelton, An Atlas of Victorian Mortality (Liverpool: Liverpool University Press, 1997); Bill Luckin and Graham Mooney, ‘Urban History and Historical Epidemiology: The Case of London, 1860–1920’, Urban History, 24 (1997), 37–55; Simon Szreter and Graham Mooney, ‘Urbanization, Mortality, and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in 19th-Century British Cities’, Economic History Review, 51 (1998), 84–112; Graham Mooney, ‘Infectious Diseases and Epidemiologic Transition in Victorian Britain? Definitely’, Social History of Medicine, 20 (2007), 595–606; E. A. Wrigley, Poverty, Progress, and Population (Cambridge: Cambridge University Press, 2004). E. P. Thompson, The Making of the English Working Class (Harmondsworth: Penguin, 1968). In The Bleak Age (London, [1934] 1947), J. L. and Barbara Hammond dedicate a chapter to public health, but more than passing attention to health is rare. S. E. Finer, The Life and Times of Sir Edwin Chadwick (London: Methuen 1952); R. A. Lewis, Edwin Chadwick and the Public Health Movement, 1832–1854 (London: Longmans, Green, 1952). These followed the magisterial survey by W. M. Frazer, A History of English Public Health (London: Baillière, Tindall and Cox, 1950), and preceded an equally impressive biography of Sir John Simon by Royston Lambert, Sir John Simon and English Social Administration (London: McGibbon and Kee, 1965).

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30. Thompson, Making of the English Working Class, 376; Hammond and Hammond, The Bleak Age, 225. 31. John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990). 32. Peter Baldwin, Contagion and the State in Europe, 1830–1930 (New York: Cambridge University Press, 1999). 33. R. McGrew, Russia and the Cholera, 1823–1832 (Madison: University of Wisconsin Press, 1965); R. McGrew, ‘The First Cholera Epidemic and Social History’, Bulletin of the History of Medicine, 34 (1960), 61–73; Michael Durey, The Return of the Plague: British Society and Cholera, 1831–2 (Dublin: Gill and MacMillan, 1979); Louis Chevalier, ‘Introduction Générale’, in idem (ed.), Le Choléra: La Première Épidémie due XIXe Siècle (La Roche-surYon, 1958); Asa Briggs, ‘Cholera and Society’, Past and Present, 119 (1961), 76–96; Charles Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962); idem, ‘Cholera in Nineteenth Century Europe: A Tool for Social and Economic Analysis’, Comparative Studies in Society and History, 8 (1966), 452–63; Christopher Hamlin, Cholera: The Biography (Oxford: Oxford University Press, 2009). 34. F. B. Smith, The People’s Health, 1830–1910 (New York: Croom Helm, 1979). 35. Michel Foucault, Naissance de la clinique: une archéologie du regard médical (Paris: Presses universitaires de France, 1963), appearing in English as Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. Alan Sheridan (New York: Random House, 1973); Michel Foucault, Surveiller et punir: Naissance de la prison (Paris: Gallimard, 1975), appearing in English as Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan (New York: Random House, 1977). 36. Christopher Kent,‘Victorian Social History: Post-Thompson, Post-Foucault, Postmodern’, Victorian Studies, 40 (1996), 97–133. 37. Susan Reverby (ed.), Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study (Chapel Hill: University of North Carolina Press, 2000). 38. Daniel Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (New York: Knopf: 1985). 39. Alan Kraut, Silent Travelers: Germs, Genes, and the ‘Immigrant Menace’ (New York: Basic Books, 1994). 40. Judith Walkowitz, Prostitution and Victorian Society: Women, Class and the State (Cambridge: Cambridge University Press, 1980); Paul McHugh, Prostitution and Victorian Social Reform (New York: St. Martin’s Press, 1980). 41. E. Richard Brown, Rockefeller Medicine Men: Medicine and Capitalism in America (Berkeley: University of California Press, 1979); Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines (Durham, NC: Duke University Press, 2006); Charles Briggs and Clara Mantini-Briggs, Stories in the Time of Cholera: Racial Profiling during a Medical Nightmare (Berkeley: University of California Press, 2003). 42. Amy L. Fairchild, Ronald Bayer, and James Colgrove, Searching Eyes: Privacy, the State, and Disease Surveillance in America (Berkeley: University of California Press, 2007). 43. Nadja Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 1853–1907 (Durham, NC: Duke University Press, 2005). 44. Richard Preston, The Hot Zone (New York: Random House, 1994); Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World out of Balance (New York, 1995); Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health (New York: Hyperion, 2000).

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45. Mervyn Susser, ‘Epidemiology in the United States after World War II: The Evolution of Technique’, Epidemiologic Reviews, 7 (1985), 147–77. 46. Linda Nash, Inescapable Ecologies: A History of Environment, Disease, and Knowledge (Berkeley: University of California Press, 2006). 47. An early compendium was Samuel Epstein, The Politics of Cancer, rev. edn (New York: East Ridge Press, [1978] 1998); Michael Edelstein, Contaminated Communities: The Social and Psychological Impacts of Residential Toxic Exposure (Boulder: Westview Press, 1988). 48. Alan Petersen and Deborah Lupton, The New Public Health: Health and Self in the Age of Risk (London: Sage, 1996). 49. Steven Epstein, ‘Democracy, Expertise, and Activism for AIDS Treatment’, in Randall Packard et al. (eds), Emerging Illness and Society (Baltimore: Johns Hopkins University Press, 2004), 102–20. 50. Porter, Health, Civilization, and the State, 309–13. 51. ‘Justice’ was an afterthought in the title of my book Public Health and Social Justice in the Age of Chadwick (Cambridge: Cambridge University Press, 1998), a shorthand to deal with the broader phenomena of inequality. 52. David Barnes, The Making of a Social Disease: Tuberculosis in Nineteenth-Century France (Berkeley: University of California Press, 1995); Barron Lerner, Contagion and Confinement: Controlling Tuberculosis along the Skid Road (Baltimore: Johns Hopkins University Press, 1998). 53. James Colgrove, Gerald Markowitz, and David Rosner, ‘Introduction: The Contested Boundaries of Public and Population Health’, in eidem (eds), The Contested Boundaries of American Public Health (New Brunswick, NJ: Rutgers University Press, 2008), 1–12.

Select Bibliography Finer, S. E., The Life and Times of Sir Edwin Chadwick (London: Methuen, 1952). Foucault, Michel, Surveiller et punir: Naissance de la prison (Paris: Gallimard, 1975), published as Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan (New York: Random House, 1977). Hamlin, Christopher, Public Health and Social Justice in the Age of Chadwick (Cambridge: Cambridge University Press, 1998). Nash, Linda, Inescapable Ecologies: A History of Environment, Disease, and Knowledge (Berkeley: University of California Press, 2006). Porter, Dorothy, Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times (London: Routledge, 1999). Rosen, George, A History of Public Health, expanded edn, ed. Elizabeth Fee (Baltimore: Johns Hopkins University Press, 1993). Rosenberg, Charles, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962). Sand, René, The Advance to Social Medicine (London: Staples Press, 1952). Simon, John, English Sanitary Institutions Reviewed in Their Course of Development, and in Some of the Political and Social Relations (2nd edn, London, 1897). Smith, F. B., The People’s Health, 1830–1910 (New York: Croom Helm, 1979).

chapter 24

the politica l econom y of hea lth ca r e in the n i n eteen th a n d t w en tieth cen t u r ie s m artin g orsky

Historians who launch their narratives with great men, pivotal dates, and legislative milestones are almost certainly guilty of crude reductionism. Yet it is hard to resist beginning with Germany’s Chancellor Otto von Bismarck (1815–98) and the passage in 1883 of his Gesetz betreffend die Krankenversicherung der Arbeiter (Law Concerning the Sickness Insurance of the Worker), which is widely held to be the foundation of health provision under the modern welfare state.1 Bismarck’s purpose was to institute a compulsory system for insuring waged labourers against sickness by providing income replacement and medical care funded with shared contributions from employers and employees. This was by no means the earliest example of organized sickness insurance, which was already deeply rooted in European civil society, and nor was it the first time the state had mandated income transfers on behalf of the sick: in Britain this may be traced to the Tudor Poor Laws. The novelty of Bismarck’s strategy lay rather in the use of compulsion to broaden the risk pool beyond selective groups and to undergird the financing of collective sickness cover. In so doing, this German statute signalled an unprecedented incursion by the state into the arena of curative medicine and raised public interest questions about the behaviour of private actors who sold medical services, whether in primary care, hospitals, or pharmaceuticals. Germany’s experiment exerted considerable influence in the industrialized nations over subsequent decades, though with much local variation. For example, Denmark (1885) and Belgium (1894) responded by bolstering voluntary insurance with privileges and public subsidies, while Norway and Britain (both in 1911) introduced compulsion and employer contributions broadly on the Bismarckian model; France followed in 1930. War and political turbulence in the 1930s and 1940s did not sweep

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social insurance aside and from the mid-twentieth century these systems were the foundation on which universal population coverage was built. New Zealand (1941) was first to achieve this in the capitalist world, though like Britain (1948) it did so primarily on the basis of general taxation. Others advanced towards universalism using the insurance principle, whether through private, employer-based, voluntary, or public funds. The exception was the United States, still famously ‘alone amongst the developed nations’ at the millennium in lacking universal coverage.2 Here public programmes were debated several times after 1916, but rejected in favour of private or non-profit insurance and the more limited Medicaid and Medicare schemes in the 1960s. In the nineteenth and twentieth centuries, then, health care increasingly became an aspect of the economic and social policy of nation-states and the purpose here is to survey this political economy of medicine. The main aim is to account for the coming of health systems within welfare states, but also to examine how these systems responded to demographic, financial, and technological changes in the contemporary period. Constraints of space dictate a focus on major industrial economies of the capitalist world, to the exclusion of communist states and of low- and middle-income countries. Socialist systems are historically important because they treated health as a common right of citizenship to be met through central planning, while transitional and poorer nations illuminate the enduring legacy of imperialism: both are explored elsewhere in this volume. Further exclusions arise from my methodology, a comparative analysis of national cases selected to exemplify different models of health system. Typologies are legion (‘entrepreneurial, welfare-oriented, comprehensive’, ‘private, pluralistic, national health insurance, national health service’, and so on), although the relative importance of private and public forms of financing and provision has typically underpinned classification.3 Here I discuss the United States because it has prioritized private and voluntary arrangements, Britain and Sweden because they demonstrate universal and comprehensive coverage largely with the state delivering services, and France, Germany, and Japan because they illustrate the social insurance principle, alongside a regulated private sector. Through most of history, medical encounters in the West were individualized market transactions or occurred in institutions organized by religion and charity. The question of why the state entered, and then came to dominate, this arena in the recent past is therefore of over-arching importance, and the first section summarizes common theoretical approaches advanced to explain this process. The second section outlines the nineteenth-century foundations of social insurance and public provision of medical facilities on which state engagement was built. The following sections trace the growth and development of health systems in the case-study countries, dividing events into three broad periods: the early twentieth century, in which they were largely put in place; the post-war ‘golden-age’ of the welfare state; and attempts since the 1970s to reform health systems in response to burgeoning costs and ideological critique. The conclusion reflects on how the different models adopted have impacted on population health.

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From a methodological perspective it is important to recognize that health care has been a subject of fierce, sometimes vituperative, debate in recent democratic politics, and the Anglophone comparative literature is inevitably influenced by this. In particular, the ‘lessons’ that Europe might supply to their own country marks the work of American scholars. Nor is the terminology transparent or value free, since tropes such as ‘health security’ and ‘socialized medicine’ carry current political resonance. Even the common term ‘health system’, which helpfully denotes national arrangements for the financing, provision, and regulation of health care, is not neutral, dating to the interwar period when its usage signified the desirability of service integration and collective financing instead of an unfettered marketplace.

Theorizing health system histories Theoretical analysis of the emergence of health systems is intertwined with the larger problem of explaining the welfare states of which they are a part. Evidently these were products of economic modernization, for industrialization generated the surplus wealth to fund insurance or tax-based services while also removing existing supports of kinship, church, guilds, and paternalism.4 But what was the process by which new forms of social protection emerged? One approach treats them as an essentially pragmatic reaction to the dislocations caused by economic liberalism. Thus, for example, Polanyi looked to anthropology to demonstrate the embeddedness of reciprocity and redistribution in human behaviour, and treated social legislation as ‘protective counter-moves’ against the inherently ‘self-destructive mechanism’ of free markets and the risks posed to life and labour in the industrial cities.5 Readings such as this minimize the importance of agency: welfarism was driven neither by class politics nor ideology; instead it ‘simply responded to the needs of an industrial civilization with which market methods were unable to cope’.6 Modernization theorists with a Marxist perspective place greater emphasis on the interests of ruling classes in effecting change. First, welfare states subsidized capital in reproducing labour power, with health and education fostering human capital, and they sustained economic efficiency, with pensions and social security regulating the labour market and maintaining demand.7 Second, they mediated the class tensions to which industrialization gave rise. Welfare legislation was ‘property’s ransom for security’ and the redistributive elements of health systems a concession made to legitimize the social order and stave off revolutionary change.8 A prime piece of evidence is the ‘Imperial Message’ introducing Bismarck’s legislation, which stressed the ameliorative value of health insurance in the wake of laws prohibiting political activities of labour organizations: ‘the healing of social wrongs must be sought not solely through the repression of social democratic excesses but by positively advancing the well-being of the workers’.9 However, neither ‘productivist’ nor ‘legitimation’ theories seem wholly adequate, given the scale of redistribution and the advance of equity that were

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achieved. Surely efficiency and social conciliation could have been purchased more cheaply? Perhaps then explanation should concentrate on political structures and the march of democracy in the West? The British case illustrates best the contention articulated by T. H. Marshall that the extension of political citizenship brought with it the ‘social citizenship’ of welfare entitlement.10 First came the 1867 Reform Act, which enfranchised working-class males, followed by the declaration by Tory premier Disraeli that ‘the first consideration of a Minister should be the health of the people’.11 Public Health Acts in the 1870s extended the duties and capacities of municipal government in such areas as isolation hospital provision and environmental improvement. The principle of health as a public good, funded by taxation, became entrenched, and henceforth occupied the party programmes that wooed voters. Moreover, once certain social groups gained health benefits, democratic politics empowered others to achieve extensions of entitlement. Unfortunately though, there is no straightforward causal link between democratization and expanding health coverage. Imperial Germany cannot be deemed a vigorous participatory democracy in which notions of entitlement and rights were paramount. Conversely in the United States, where democracy had arrived early (at least among white American males), voters rejected social health insurance; indeed, the only referendum held on the issue, in 1917 in California, was decisive: 133,000 for, 358,000 against. Perhaps then a more satisfactory explanation of the differing forms and chronologies of national health systems lies with the political orientation of the protagonists who created or denied them. At the most general level explanation alludes to ingrained cultural values. For example, the Swedish emphasis on equality is traced right back to the Middle Ages, arising from the absence of serfdom and discernible in the Viking parliaments.12 Conversely, America’s comparatively late and limited recourse to mandated health coverage is attributed to its attachment to liberty, that ‘dominant individualism’, born of colonial rebellion and the frontier.13 Such nebulous appeals to national values are, however, hard to demonstrate empirically; for example, US opinion survey data from both the 1940s and 1990s revealed majorities in favour of more extensive state intervention than actually occurred.14 A more promising approach may therefore be to emphasize the social bases of welfare reform politics. The pre-eminent example of this treats social insurance as the achievement of the organized left, with the degree of egalitarianism determined by the strength of the labour movement allied with socialist parties. Scandinavia provides the locus classicus, with the universal coverage and equitable access of the Swedish health system attributed to the long period of Social Democrat parliamentary dominance in the midand late twentieth century. The creation of the British National Health Service (NHS) during a rare interregnum in which Labour held a sweeping parliamentary majority is another example. Again though, the ‘labour mobilization’ thesis fails to provide a comprehensive explanation. The extension of post-war coverage in countries like France and Germany, from limited social insurance in the late 1940s to almost universal inclusion by the 1960s, was not the outcome of a leftwards shift, but rather of the changing interests of other groups.15

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A compelling version of the socio-political account therefore concentrates on understanding these solidaristic moments, in which working- and middle-class interests aligned sufficiently to enable the enactment of welfare legislation. The notion of solidarism is not understood in ethical terms, as middle-class humanitarianism, but rather as the outcome of self-interest, for all may stand to gain from universalist or egalitarian health systems. Thus, in Baldwin’s words, a social constituency’s attitude to welfare is determined not by its ‘relations to the means of production’, but rather its ‘relations to the means of security’.16 For example, in this light, Swedish progress towards universal coverage is better explained by the ‘red-green alliance’ of a powerful left and an agrarian party that wanted health insurance extended to the farming sector. Complementing this argument is the position of historical institutionalists, such as Immergut, who argue that solidaristic alliances alone are not sufficient to explain change or stasis. For them the over-arching determinant is the political framework in which health care legislation is debated and the scope which institutional structures provide for opponents to frustrate reform. A strong executive committed to change and reliant on unified party support may override hostile interest groups like private insurers, professional associations and pharmaceutical companies: the treatment of the British Medical Association (BMA) by Lloyd George in 1911 is a case in point. However, executive will and broad social support for change can be frustrated if the political system contains sufficient ‘veto points’ at which interest groups may block legislation. The United States, with its loose party discipline, tolerance of pressure group financial activities, and its legislative process of passage through House, Senate, and congressional committees, provides many such veto points, where arguably successive health bills have foundered. One interest group above all dominates histories of the political economy of medicine. In entering the field of health, the state challenged the independence of the medical profession. Whether through its role in purchasing or providing health services, the welfare state threatened doctors’ cherished rights to diagnose and prescribe as they considered best. More prosaically its monopoly power might also drive down the price they charged. During the nineteenth and early twentieth centuries, the consolidation of professional associations promoted the interests of trained practitioners by differentiating them from the many irregulars jostling in the medical marketplace. Thus not only did doctors have local and national organizations through which to combat proposals they disliked, but they also had the expertise vital to the functioning of health systems. This gave them greater leverage than other producer groups within welfare states in the pressure politics that determined the form health systems took. The discussion that follows will not attempt to distil a unitary theory from this contested terrain of welfare state historiography. However, it will allude to cases when productivism and legitimation seem to have motivated the hierarchical imposition of reform. It will also highlight the different institutional structures in which social constituencies were mobilized and interest groups operated. First, though, how were health services delivered prior to the entry of the state?

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Before the welfare state The precursors to national health insurance were the contributory sickness funds that flourished in the nineteenth century, and whose own institutional antecedents were the early modern craft guilds. These were corporate bodies whose main purpose was the economic regulation of a skilled trade, but which also had welfare roles. The emergence of journeymen’s associations concerned specifically with burial and health insurance, and funded by fixed dues, was apparent by the mid-eighteenth century. A transition from craft guilds to ‘friendly societies’ based on networks other than occupation seems to have occurred first in Britain, where membership expanded particularly (though not exclusively) in the heartlands of the Industrial Revolution. Alehouse sociability for male workers coloured their world and enshrined an ethic of patriarchal stewardship through collective endeavour. ‘Open’ societies emerged in other countries, such as post-revolutionary France, where mutualités were associated with locality and church, and Sweden, where they flourished in large towns. Income replacement was the key benefit, with the formal involvement of medical practitioners only gathering pace during the nineteenth century, first as ‘gatekeepers’ of the fund, authorizing claims and vetting neophytes to avert adverse selection, and only later providing medical treatment to speed recovery. States had shown an interest in these mutual associations long before 1883, in part because they promised to reduce the tax burden of the local poor law. In Prussia, communities were empowered to enforce membership (1845, 1848) in either occupational or locally run funds, and from 1854 this became mandatory in mining and foundries. Policy might also be aimed at strengthening the security of the funds, as with the British strategy of encouraging investment in government stock at preferential rates. Another concern was to detach the welfare role of workers’ sickness funds from the industrial activities of organized labour. For example, German legislation in 1876 limited them to benefit functions, though also establishing the enduring principles of employer contributions and self-government. In France, Bonapartist policy (1852) gave preferential treatment to mutuals managed and financially supported by local elites, thus lending the movement a ‘rigidly conservative’ character.17 After 1883, some liberal states continued this approach of bolstering voluntary insurance as a deliberate alternative to the Bismarckian model. Thus France’s Mutual Charter (1898) permitted diversification and mergers, as well as boosting state subsidies, a strategy also adopted in Sweden (1891) in preference to compelling employer contributions. For all their pioneering work, mutualist associations did not succeed in extending insurance throughout the population. Leaving aside the issue of achieving actuarial viability during a period of falling mortality and rising morbidity, the key challenge was the stability and level of income required to fund subscription over the life course. While they were certainly not the sole preserve of the skilled working class there were clear limits to coverage: Britain (12.5 of the population in 1872) was slightly ahead of

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Germany (9.5);18 Sweden’s membership was predominantly urban, and only took off following the start of subsidies; while French mutualism similarly relied on subsidies and honorary contributions. In America, coverage was extensive among the industrial workforce, though excluded medical attendance. And although the mutualist savings model was not solely Western, Japan seems to have had no similar precedent; here domiciliary medical care was privately remunerated, with doctors paid twice yearly, nominally for the drugs they prescribed. Communal arrangements for providing hospitals for the poor also have a distant history, in medieval charitable foundations endowed by urban elites. The entry of the modern state may be dated to the seventeenth century, with the building of the French hôpitaux généraux and the British urban workhouses. Initially intended to discipline mendicants, in practice the ‘great confinement’ soon became limited to orphans and the nursing care of the chronic sick, with limited medical attendance. Mental health was another area where market and philanthropy proved insufficient and in Britain, for example, the early nineteenth century saw the start of an asylum-building programme based on local taxation. Alongside these institutions were charity hospitals for the poor, in which acute medicine was practised and teaching delivered. Poor law approaches were also adopted in the United States, where public ‘almshouses’ accommodating older people, the mentally ill, and vagrants gradually became differentiated by specialism. Distinctive trajectories emerged in the nineteenth century. Philanthropy proved insufficient to sustain the expansion of American voluntary hospitals, and patient payments became accepted practice; the proliferation of smaller proprietary hospitals further embedded the acceptance of user fees. Different again was Scandinavia, where the insufficiency of aristocratic philanthropy put the onus onto the ‘welfare municipality’.19 In Sweden, the creation of county councils with powers of tax raising and hospital administration (1862) accelerated new foundations staffed by salaried physicians; here poverty and low population density impeded the growth of private medicine and most practitioners relied at least in part on a public appointment. The state also loomed large in Japan, though here as a result of the Meiji policy decision to replace indigenous healing with European biomedicine; there had been no prior tradition of charitable provision and beyond the medical schools public institutions were limited to a few military and municipal poor hospitals. Crudely then, while Scandinavia’s unitary tax-funded hospitals laid the foundations of a ‘social democratic’ model, elsewhere the forerunners of ‘liberal democratic’ health systems operated public institutions catering mainly to the dependent poor and voluntary or proprietary hospitals for the ‘respectable’ population.20 Stigma and underresourcing attached to the former, status and scientific repute to the latter, though by 1900 both types of institution still intended their services for poorer people. This though was starting to change, as rising faith in biomedicine, post-Pasteur, coupled with technological transformation made hospital admission attractive to the middle classes. Shifting patterns of demand and the escalating costs of medical care posed new questions of access and funding for governments.

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Health systems in welfare states 1883–1945: Social insurance versus private interests As noted above, the case of Germany is fundamental to understanding the coming of health systems in welfare states. First it is important to correct two misconceptions about 1883. Though associated with Bismarck, credit for the legislation belongs to Theodor Lohmann (1831–1905), a Christian social reformer and civil servant. Lohmann’s interest lay in integrating the worker into society through institutions that furthered moral development, in contrast to Bismarck’s more autocratic notion of binding the subject to the state: hence the reform built on existing mutual aid associations, rather than a single bureaucratic fund preferred by Bismarck. More crucially, new research has revealed that Bismarck’s prime motivation was not to pacify the left. Instead his ‘carrot and stick’ rhetoric was primarily designed to satisfy the Kaiser and sceptics in the Reichstag. The real agenda, first with accident insurance, the precursor, and then with health insurance, was to aid German productivity. Compulsory coverage against accidents streamlined a system becoming mired in costly workmen’s compensation cases while sickness insurance also aimed to boost economic growth, not least by aiding the mobility of labour.21 Thus ‘legitimation’ now seems less important than ‘productivism’ in explaining the first case of state intervention. These factors can also be discerned in the enactment of national health insurance (NHI) in Britain (1911) and Japan (1926). Of course, this is also explicable as a policy transfer: the German innovation had its adherents among Japanese and British civil servants. However, both nations legislated at a time of incipient labour movement strength and in neither case was NHI part of the social democratic programme. Britain’s Labour Party had recently won its first election victories and trade union membership had climbed steeply to 2.5 million in 1907.22 The background to Japan’s Health Insurance Act was the growth of a socialist movement, the granting of universal male suffrage (1926), and the repressive Peace Preservation Act (1925), which proscribed leftist groups. The importance of population health to imperial economies also loomed large. The debilitated state of army recruits in the Boer War had scandalized British public opinion and the welfare reform era also inaugurated a school medical service. Nationalist and militarist imperatives in Japan drove the expansion of NHI beyond large companies by establishing subsidized, locally based funds to cover the self-employed in rural areas (1938), then incorporating white-collar workers (1941) so that coverage exceeded 70 by 1943. Germany, the pioneer, was also first to confront the inherent conflict between provider interests and NHI funds, as growing coverage threatened the market for private medicine. Doctors formed a national association, the ‘Hartmannbund’, and in 1911 forced two key concessions, a free choice of physician by the insured and payment based on fee for service determined by the doctor. Soon after, in 1913, corporatist regional machinery was established through which doctors could negotiate with funds to resolve

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contentious issues such as remuneration. Britain by contrast drove a tougher bargain, conceding free choice of doctors on a local ‘panel’, but remunerating according to capitation (the number of patients on a practitioner’s list) with the level set well below that demanded by the BMA. The result though was to discourage doctors from treating the insured as generously as their private patients, and to embed a less expansive approach in the British system. As the viability and popularity of NHI became evident, other liberal states confronted the interest politics standing in the way of its establishment. France’s preference for voluntary solutions was undermined by the 1919 peace settlement, in which it regained Alsace-Lorraine from Germany, incorporating a population enjoying Bismarckian health insurance. French labour (though not the communists) endorsed proposals for NHI and solidaristic support deepened as the petite bourgeoisie recognized the advantages to be gained from access to hospital care. Observing the political mood, centrist doctors struck a compromise, accepting NHI in return for concessions. Thus the Social Insurance Law (1930) made enrolment in the existing mutuals compulsory for bluecollar employees, extending by 1939 to about half the population. It also enshrined a ‘medical charter’ guaranteeing free choice of practitioner and remuneration by fee for service, with reimbursement claimed by the patient, not the doctor. Solidarism and a favourable institutional context eased the process in Sweden, which in 1931 advanced towards NHI through rationalizing the subsidy system for mutuals and standardizing their medical benefits. Here reform proposals emanated from the Liberals and a consensus including social democrats and employers was forged within a committee system, through which pre-legislative objections were resolved outside the politicized parliamentary arena. Although the Swedish Medical Association appealed to conservative politicians to veto change the latter were unwilling to disrupt this accord. In the United States meanwhile, reform efforts met with failure. In the 1910s NHI proposals for blue-collar workers were put forward by Progressive intellectuals and the American Association for Labor Legislation, based largely on productivist arguments. Several state legislatures discussed and rejected such plans, before war with Germany and isolationist suspicion of European innovations terminated the policy debate. In the New Deal era President Roosevelt briefly considered reviving NHI in his 1935 social security bill, which laid the basis of America’s welfare state. However, fearing that its political contentiousness might endanger other parts of the bill, he set it aside. As the New Deal gave way to wartime mobilization, Congressional Democrats tried again in 1939 and 1943, though without success. Why the different outcome? First, there was no legitimation imperative, as the state did not confront a social democratic political party threatening the status quo. Second, labour did not uniformly mobilize behind NHI. Like their European counterparts, some leaders initially feared health insurance would undermine trade unionism and the struggle to raise wages. Moreover, existing industrial sickness funds were extensive and robust and the Progressive alternative looked financially unattractive. The scope for a solidaristic alliance with less fortunate groups was further narrowed in the 1930s and 1940s with the rapid rise of the voluntary sector Blue Cross and Blue Shield prepayment plans, widely offered as a benefit in the

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wartime labour market. Third, institutional factors accorded hostile interests, such as employers, commercial insurers, and doctors, the opportunity to obstruct legislation. In particular, the wealth and organization of the American Medical Association (AMA) underpinned propaganda campaigns that influenced public opinion and stymied consensus, even against the wishes of the executive. The weak party whip permitted vested interests considerable influence over legislators, with Southern Democrats notably impeding reform attempts in the mid-twentieth century.23 Turning now from payment mechanisms to service provision, the early twentieth century also saw an increasing public role. In part this followed the concentration of expertise in the hospital, alongside technological changes such as laboratories, X-rays, and radiotherapy equipment. This broadened the social base of utilization: in Paris, for example, the proportion of births in hospital rose from about 55 in 1912 to 79 in 1919.24 Gradually the vestiges of refuge and stigma were shed from British workhouse infirmaries, the French ‘maison de pauvres’, and major public hospitals in the United States. Thus in France a state-funded building programme underwrote departmental hospital centres and from 1926 opened public institutions to private or means-tested patients; as NHI expanded, so demeaning ‘assistance’ transmuted into ‘assurance’. In Britain many municipal hospitals were taken out of the poor law, bringing greater investment and integration with local voluntary institutions and medical schools. As in America, the voluntary/public distinction remained in place, though the rise in demand and escalating costs saw the dwindling of hospital philanthropy, to be replaced in Britain by the mass contributory schemes, and in the United States by Blue Cross, user fees, and group pre-payment arrangements, such as the Kaiser plan introduced in 1938. The interwar labour movement increasingly advocated access to health care, but with mixed results. In Britain, the left was uncertain whether to support the extension of NHI or a tax-funded local government service, and in the event it was Conservative legislation that refashioned the poor law and expanded municipal medicine. Leftist initiatives elsewhere capitalized on the purchasing power of insurance funds. In Germany, the selfgoverning structure of the Krankenkassen encouraged experiments that challenged the market in the interest of the patient. These included efforts to standardize prescription costs and the foundation of polyclinics run by salaried physicians and providing comprehensive services. Such innovations were condemned by local doctors as ‘Marxist power lust’ and the profession subsequently aligned itself with the Nazis, benefiting from their purge of socialist fund representatives, as well as Jewish and radical doctors.25 A ban on polyclinics, state control, and the loss of the workers’ majority quickly followed, though otherwise the core functions of NHI were compatible with the population policies of fascism. Similarly, in Japan, communist-sponsored hospitals and clinics for farmers and workers mounted a short-lived challenge to private medicine before suppression in the 1930s. Here it was militarism, not socialism, which challenged the market, with the government’s ‘Healthy People, Healthy Soldiers’ programme driving health-centre development, followed by the wartime nationalization of hospitals under the Japan Medical Corporation (1942). Thus although labour mobilization behind health-systems reform was discernible by 1945, it was not a decisive force.

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1945–1975: Health systems in the ‘golden age’ Growth economists characterize the three post-war decades as a ‘golden age’ in Western Europe and Japan, with per capita gross domestic product (GDP) rising at unprecedented rates between 1950 and 1973.26 Prosperity was driven by many factors, including the impact of the Marshall Plan, technology transfers of American production techniques, high investment rates, ample and mobile labour, and a long period of political stability founded on national institutions that sustained social consensus. Central to these were welfare states, and the keynote of this phase of health system development was expanded population coverage and escalating expenditure. Sturdy comparative data on health spending became available from 1960 and, as Figures 24.1 and 24.2 show, this rise was evident in real terms and as proportion of GDP. The long-run climb in real expenditure reflects two factors above all: the costs of the labour and technology of curative medicine; and the ever-growing demands arising from greater longevity and the morbidity of older people. The differing national trajectories, however, demand explanation. A combination of labour mobilization, solidarism, and institutional factors meant that Britain moved decisively away from its mixed economy of health care. At a stroke, the NHS (1948) brought universal coverage, funding from general taxation, and state provision of facilities free at the point of use. Though characteristically attributed to the

3,500.00 3,000.00 2,500.00 $ 2,000.00 1,500.00 1,000.00 500.00

France

Japan

United Kingdom

Germany

Sweden

United States

04 20

00 20

96 19

92

88

19

19

84 19

80 19

76 19

72 19

68 19

64 19

19

60

0.00

figure 24.1 Per capita health expenditure in selected developed nations, US$ (purchasing power parity) at constant prices (1983). Source: OECD Health Data 2008—Selected Data. URL: http://stats.oecd.org/index.aspx

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16 14 12 10 %

8 6 4 2

France

Japan

United Kingdom

Germany

Sweden

United States

04 20

00 20

96 19

92 19

88 19

84 19

80 19

76 19

72 19

68 19

64 19

19

60

0

figure 24.2 Health expenditure as percentage of GDP in selected developed nations. Source: OECD Health Data 2008—Selected Data. URL: http://stats.oecd.org/index.aspx

progressive left, personified by Labour’s Minister of Health, Aneurin Bevan, it built on bipartisan consensus. Broad support for welfarism was fostered by the 1942 Beveridge Report (in which health barely figured), and while wartime social solidarity should not be exaggerated, an appetite for change produced a large Labour majority in the 1945 election. This provided an opportunity for a decisive executive with a broadly united cabinet to carry a fundamental reform. There were, however, limits to its radicalism. Private medicine was still permitted, with user fees soon returning for dentistry and prescriptions, and there was no place for the grassroots participation hitherto encouraged by local politics or voluntary action. Alongside a ‘democratic deficit’, the other serious charge is that Bevan’s model institutionalized frugality. As the expenditure data show, the single-payer system, where the Treasury set a global budget, was comparatively highly effective in cost containment. In the early years such parsimony was not politically problematic and after a straitened start investment began to flow to hospitals and primary care. Elsewhere proposals for deep reform in the post-war moment had more muted results. The West German left pushed for a single insurance fund to replace the existing Krankenkassen, with the prospect of monopoly power ensuring equitable benefits. However, the election of conservative Christian Democrats in 1949 meant that the system was rebuilt on similar principles to the Nazi era.27 Swedish socialists also proffered a radical blueprint for replacing private medicine with a salaried service based in state

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health centres. This time Sweden’s deliberative committee system allowed opponents to resist this, although 1955 saw the establishment of NHI with fee for service reimbursement; universal coverage was achieved by 1962. In Japan too there was discussion of a national health service patterned on the wartime emergency structure, but this was blocked by American occupying forces. Hospitals reverted to private ownership and most physicians remained in private practice; the tripartite insurance structure stayed in place, with employer, government, and subsidized community funds. Post-war planners in France also created a new political and social compact, carried through by de Gaulle, who capitalized on a mood of national unity. The Social Security Law (1945) established compulsory health insurance run by statutory funds, under the democratic management of boards dominated by trade unions. Again though, radicalism was limited: coverage was not universal, medical practitioners continued to set billing levels, and the existence of co-payments guaranteed the survival of the mutualités. These structures provided the basis on which universal coverage was achieved. Explanation emphasizes social conciliation in Japan, with mandatory insurance finally introduced in 1958 by a conservative government after socialist electoral success in rural areas. In France and West Germany, analysis highlights another solidaristic moment in the 1960s, when the relatively poor position with regard to welfare entitlements of small businesses, the agricultural sector, and some professionals and managers prompted these groups finally to embrace statutory insurance.28 Both nations achieved virtually complete coverage by the early 1970s. Only in America was a different path taken. Here the post-war window had seen reform fall due to familiar institutional and pressure group factors, with AMA propaganda now playing on incipient Cold War sentiment to tarnish NHI as either socialist or fascistic. Other than federal support for hospital building, US policy now relied on the voluntary and private sectors to deliver population coverage. By the early 1960s, it was apparent that the post-war boom had extended this to only some 75 of the population and Democratic Congressional strength in the Johnson era, coupled with self-interested solidarism of older citizens, opened the way to new initiatives. This was the creation of Medicare, under which the elderly received medical benefits under Social Security and subsidized insurance, and of Medicaid, a limited safety net for the uninsured poor.29 These were the settings for the upward course of real expenditure. The higher costs of America’s system were evident by the 1960s, as providers responded to the new incentives of Medicare reimbursement by increasing their activities. Japanese spending grew from a low base, its rise reflecting expansion in privately owned hospital bed capacity and the decision in 1972 to lift co-payments for older people, meeting excess costs from general taxation. As in Germany, a stable corporatist negotiating structure allowed Japanese doctors and bureaucrats to agree a uniform fee schedule that moderated expenditure growth. France and Germany meanwhile, starting from a higher base, found the fee-for-service model inflationary; Germany’s differentiation between the industrial and white-collar funds (Ersatzkassen), with high earners opting into private insurance, created a further ‘ratcheting up’ effect, as the better benefits enjoyed by the few were increasingly desired by the many. Like Japan, 1960s France took steps to rein

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back doctors’ charging practices by compelling them to agree contracts with the Sécurité Sociale, binding them to a fee schedule. Even so, practitioner earnings continued to rise as new technology allowed them to intensify their activities. Nor were the tax-based systems necessarily more restrained, as Sweden, which combined fee-for-service NHI reimbursement and county-level tax-financing, demonstrates. A combination of social democratic political control and traditional willingness to fund municipal hospitals kept spending high. The leftist hegemony also saw private medicine in retreat before a salaried service delivering care through public health centres and hospitals, though this did not restrain costs. Here and elsewhere, containment would not begin until changes in the macro-economic environment ended the expansionary phase.

1975–c.2005: The ‘crisis’ of the welfare state The mid-1970s saw a halt to the era of buoyant economic growth. Investment rates fell, while oil shocks prompted escalating prices and wage demands, heralding a period in which inflation and unemployment rose simultaneously. The social and political compact sustaining welfare states began to founder as conservative politics returned, accompanied by neo-liberal critiques of ‘provider capture’ and bureaucratic inflexibility. Expenditure curbs and strategies to enhance efficiency therefore characterize this period, though different approaches were employed and different spending trajectories resulted. Despite all the talk of a fiscal and political crisis of the welfare state, overall health expenditures broadly maintained their upward course, as Figures 24.1 and 24.2 show. These do not differentiate public from private spending, but if they did they would reveal a similar trend. In the United States, for example, the costs of Medicare, Medicaid, and other public programmes climbed from 2 of GDP in 1976, to 2.9 in 1989, to 4 by 1993, and 5 in 2005.30 This is because the inflationary drivers of technological change in medical science and the demands of an ageing population still remained. Drug costs were a key factor, representing about 14 of health expenditures in the six countries, 1980–2005. Figures 24.1 and 24.2 also suggest that despite rising real costs states successfully reined back outlays as a proportion of national wealth, though chronologies of containment varied. The British single-payer system presented the Thatcher/Major governments with a lever to achieve this, though legitimation concerns compelled them to ensure the NHS’s core principles remained ‘safe with us’.31 Policy therefore focused on lifting productivity with fewer resources, initially through managerial reforms designed to improve cost-effectiveness. Next came a re-fashioning of governance structures to establish a quasi-market, in the expectation that internal commissioning would introduce competitive efficiencies. Labour’s return brought higher investment but broad policy continuity, now with private sector contracting for capital projects and tougher regulation of drug treatments through the National Institute of Clinical Excellence. Sweden deployed similar policies. Ceilings on local taxation were imposed and hospital funding moved from a calculation based on patient visits to a more restrictive capitation

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basis. Conservative revival in the 1990s brought experimentation with a British-style purchaser–provider split and the use of patient choice in elective surgery to instil competitive incentives. Private medical practice in hospitals and health centres also reemerged, though here too the political premium on equity ensured the continuing predominance of public financing and anxieties about spatial and social justice. In countries that combined social insurance with predominantly private supply the focus was on the charging practices of health providers. Germany moved in the 1980s to enforceable regional budgetary caps, then to federal price-setting of drug costs with copayments for expensive prescriptions. The peculiar challenge of integrating the East German system after reunification (1990) was met by tightening reimbursement practices, for example fixing fees according to diagnosis, and by the cross-subsidization of poorer funds by the wealthy. This cross-subsidization device had been tried earlier in Japan to tackle the disadvantage of community funds with greater numbers of impoverished older people. As in Britain, a rightwards political shift in the 1980s saw Japanese policy towards providers become more assertive, with a biennial price survey to hold down pharmaceutical costs and a stricter doctors’ fee schedule that compensated for the ‘natural increase’ in their volume of work. France too tackled doctors’ charges, here subject to upward pressure because supplementary insurance and co-payments encouraged billing in excess of approved fees. Tax and pension incentives now bound doctors into the fee schedule, while global budgets were set for hospitals in place of individual negotiation. However, conservative attempts at imposing tighter controls in the 1990s were blocked by labour mobilization, aligned with the self-interest of practitioners. Juppé’s proposals included a national health budget, restrictions on clinical freedoms in respect of costly drugs and therapies, and limiting patients’ free choice of specialists. Their defeat left France amongst the highest spending nations at the new millennium. As to the biggest spender, why did the 1980s see America’s medical costs diverge irreversibly from its peers? The pursuit of profit in private health care had intensified as large corporations superseded small firms in hospital management and supplies, forcing non-profit providers towards more commercial practices. President Reagan’s introduction of a European-style fee schedule for Medicare reimbursement (1983) could not stifle inflationary pressures, which now came from new, largely private sector actors, the Health Maintenance Organizations, introduced by President Nixon to encourage membership of group prepayment plans. Nor had these solved the problem of incomplete coverage and the Clinton presidency began with a complex health reform proposal. This suggested mandatory employer contributions and state-level ‘alliances’ to achieve universalism, and federal regulation of private plans to control costs. As previously though, the favourable conjunction of circumstances required for success was absent. Solidaristic support was elusive, with labour already alienated after Clinton’s embrace of free trade and the comfortable middle class fearful of new spending obligations, thanks to the Republican legacy of public indebtedness. Institutional and pressure group factors also resurfaced, this time with insurers leading the propaganda war and conservative Democrats from the South and West once more undermining congressional party unity. Again reform prospects faded and incomplete coverage remained. By 2006, 46 million

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Americans lacked health insurance and the promise of another reform attempt was central to Democratic resurgence under Barack Obama. His Patient Protection and Affordable Care Act of 2010 (to be phased in by 2014) aimed to extend cover and restrain costs. The strategy was to expand coverage under the private insurance industry, using a mix of subsidies, incentives, and mandates on individuals and employers, and to increase consumer protection for the insured. A more radical option suggested by the President, of a public health insurance plan that might have competed with private providers, was rejected by Congress. Despite this, the Act provoked great political bitterness and was met by threats of repeal by Republicans.

Conclusion By the later twentieth century, then, advanced capitalist nations all operated health systems that combined insurance, tax-funded provision, and private medicine, though the mix of elements varied substantially. In considering how and why the different national health systems developed, these limited case studies illustrate the combination of pressures—political, institutional, economic, industrial, military, ideological, and professional—which could determine diverse outcomes. Nonetheless, readers may be asking themselves at this point whether any of this really matters. Did the type of system adopted have any bearing on national population health? International comparison to address this question has until recently relied on the gold standard indicators of life expectation and infant mortality rates (IMR). These are shown for the case study countries in Table 24.1 and demonstrate that all experienced improvements. Yet they also reveal that by the end of the twentieth century, the United States fared comparatively poorly in demographic terms, despite its far higher costs, while of the lower spenders, the United Kingdom had become worse off than Japan, which by the 1980s enjoyed the best indicators. Of the higher spenders, Sweden, with greater tax-funding and state ownership, consistently outperformed the social insurance nations, France and Germany. Of course, more comparators are needed to permit generalization and a recent survey of twenty-one European countries sought definitively to adjudicate between NHS-style and social insurance models, using time series data for 1970–2003.32 The broad conclusion was that both types of health system were converging with respect to life expectation and IMR, but that the social insurance nations historically had a slight edge. Otherwise, NHS models were better at cost-containment, though with risks of under-spending, and incurred greater patient dissatisfaction. Arguably, though, the standard indicators are misleading guides of health system productivity. After all, public health academics have long argued that curative services made only a modest contribution to the modern mortality transition and that factors ranging from income inequality to environment and individual behaviour were the key determinants of levels of sickness.33 For example, did American excess mortality result

Table 24.1 Population health indicators in selected developed nations. Life expectancy at birth Decadal mean

France Germany* Japan Sweden UK USA

Infant mortality Decadal mean

Amenable mortality Standardized death rate, ages 0–74

1960–9

1980–9

2000–5

1960–9

1980–9

2000–5

71.1 70.2 70.1 73.8 70.8 70.3

75.4 74.2 77.5 76.8 74.5 74.6

79.6 78.7 81.8 80.2 78.5 77.4

23.5 26.6 21.2 14.1 20.5 24.0

8.6 9.7 5.9 6.5 10.0 10.9

4.2 4.2 3.0 3.2 5.3 6.9

1997–8

2002–3

75.6 (1)** 106.2 (11) 81.4 (2) 88.4 (5) 130.0 (18) 114.7 (15)

64.8 (1) 90.1 (12) 71.2 (2) 82.1 (9) 102.8 (16) 109.6 (19)

* Pre-2000 data for Federal Republic of Germany only. ** Italicized number = ranking out of 19 OECD countries. Source: OECD Health Data 2008—Selected Data; E. Nolte and C. M. McKee, ‘Measuring the Health of Nations: Updating an Earlier Analysis’, Health Affairs, 27 (2008), 58–71.

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in part from the unusually high tobacco consumption of earlier birth cohorts; and did Japanese longevity owe something to benign dietary habits? In response to such criticism researchers have developed smarter metrics to isolate the contribution made by health care. This builds on the broad consensus, pace McKeown, that in the post-war period there are certain diseases whose outcomes were clearly affected by the curative services.34 One strategy has been to monitor mortality and survival rates from different cancers. Another has been to derive a composite death rate from a group of diseases whose progress is deemed amenable to health services intervention.35 Robust comparative data on ‘amenable mortality’ only extend back about thirty years but a key finding is that it has contributed significantly to rising life expectation, particularly through the impact of health services on infant mortality. Amenable mortality also provides a more sensitive gauge of comparative performance and Table 24.1 shows recent rates and rankings of the case study countries. France, which as we have seen was a higher spending, social insurance nation that historically set great store on patient choice and clinical autonomy, emerges as a top performer. Britain, an NHS system that has arguably been chronically underfunded, does poorly, though continuing improvement and the moderate rise in rankings by 2002–3 may reflect Blair’s investment hike. The United States, the highest spender with its historic attachment to market solutions, also fares badly, inviting the judgement that lack of universal coverage has disadvantaged its citizens. Such assessments, however, move from the realm of historical appraisal to epidemiological controversy and ultimately political argument. Others can and will disagree. A more modest conclusion is that the historical developments described here remain relevant, because health systems do matter to the people’s health. Yet as we have seen, an unalloyed concern to achieve the best possible standards for its citizens was rarely government’s top priority in the political economy of health care.

Notes 1. World Health Organization, The World Health Report 2000: Health Systems: Improving Performance (Geneva: WHO, 2000), 12. 2. A. Derickson, Health Security for All: Dreams of Universal Health Care in America (Baltimore: Johns Hopkins University Press, 2005), 157. 3. E. Nolte, M. McKee, and S. Wait, ‘Describing and Evaluating Health Systems’, in A. Bowling and S. Ebrahim (eds), Handbook of Health Research Methods: Investigation, Measurement and Analysis (Maidenhead: Open University Press, 2005), 12–43, 15–20. 4. G. Esping-Andersen, The Three Worlds of Welfare Capitalism (Cambridge: Polity Press, 1990), 13–14. 5. K. Polanyi, The Great Transformation: The Political and Economic Origins of Our Time, 2nd edn (Boston: Beacon Press, [1944] 2001), Chapter 4, at 79. 6. Ibid. 138–9, 152–3, at 160.

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7. C. Offe, Contradictions of the Welfare State (London: Hutchinson, 1984); I. Gough, The Political Economy of the Welfare State (Basingstoke: Macmillan, 1979). 8. The epithet derives from a speech by Joseph Chamberlain, ‘But Then I Ask What Ransom Will Property Pay for the Security Which It Enjoys?’ (1885), quoted in E. P. Lawrence, ‘George, Chamberlain and the Land Tax: A Chapter in British Party Politics’, American Journal of Economics and Sociology, 13 (3) (1954), 283–95, at 291. 9. D. Stone, The Limits of Professional Power: National Health Care in the Federal Republic of Germany (Chicago: University of Chicago Press, 1980). 10. T. H. Marshall, Citizenship and Social Class, and Other Essays (Cambridge: Cambridge University Press, 1950). 11. The context was Disraeli’s ‘sanitas sanitatum, omnia sanitas’ speech of 1872—see B. MacArthur (ed.), The Penguin Book of Historic Speeches (London: Penguin, 1996). 12. R. Saltman and S.-E. Bergman, ‘Renovating the Commons: Swedish Health Care Reforms in Perspective’, Journal of Health Politics, Policy and Law, 30 (1–2) (2005), 253–75, 254–6, 260–1. 13. Frederick Jackson Turner, The Frontier in American History (1920), Chapter 1. 14. P. Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 278–9; T. Skocpol, Boomerang: Health Care Reform and the Turn against Government (London: Norton, 1996), 13, 18–19, 108–9. 15. Esping-Andersen, Three Worlds of Welfare Capitalism, 16–18; P. Baldwin, The Politics of Social Solidarity: Class Bases of the European Welfare States, 1875–1975 (Cambridge: Cambridge University Press, 1990). 16. Baldwin, Politics of Social Solidarity, 12. 17. M. Dreyfus, ‘Mutual Benefit Societies in France: A Complex Endeavour’, in M. van der Linden (ed.), Social Security Mutualism: The Comparative History of Mutual Benefit Societies (Bern: Peter Lang, 1996), 209–24, see 211, 217–18. 18. E. P. Hennock, The Origin of the Welfare State in England and Germany, 1850–1914: Social Policies Compared (Cambridge: Cambridge University Press, 2007), 177–8. 19. T. Grønlie, ‘Norwegian General Hospitals, 1970–2002: County Ownership—An Interlude between Welfare Localism and State Direction’, Medical History, 50 (2) (2006), 189–208, 192–3. 20. T. Boychuk, The Making and Meaning of Hospital Policy in the United States and Canada (Ann Arbor: University of Michigan Press, 1999), viii–x. 21. Hennock, Origin of the Welfare State, 94–6, 159. 22. A. H. Halsey (ed.), British Social Trends since 1900, 2nd edn (London: Macmillan, 1988), 186. 23. P. Funigiello, Chronic Politics: Health Care Security from FDR to George W. Bush (Lawrence: University Press of Kansas, 2005), 47–8, 63–4, 69, 76–9, 83–6. 24. T. Smith,‘The Social Transformation of French Hospitals and the Rise of Medical Insurance in France, 1914–1943’, Historical Journal, 41 (4) (1998), 1055–87, 1060. 25. S. Liebfried and F. Tennstedt, ‘Health Insurance Policy and Berufsverbote in the Nazi Takeover’, in Donald W. Light and Alexander Schuller (eds), Political Values and Health Care (London: MIT Press, 1986), 127–84, 145–54, at 154. 26. G. Toniolo, ‘Europe’s Golden Age, 1950–1973: Speculations from a Long-Run Perspective’, Economic History Review, II, 51 (2) (1998), 252–67. 27. R. Knox, Germany: One Nation with Health Care for All (New York: Faulkner and Gray, 1993), 38.

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28. Baldwin, Politics of Social Solidarity. 29. Funigiello, Chronic Politics, 88–158; J. Engel, Poor People’s Medicine: Medicaid and American Charity Care since 1965 (London: Duke University Press, 2006), 3. 30. US Office of Management and Budget, Table 16.1, ‘Outlays for Health Programs: 1962– 2009’, http://www.whitehouse.gov/omb/rewrite/budget/fy2008/hist.html, accessed 18 September 2009. 31. Mrs Thatcher’s 1982 party conference soundbite is usually misquoted as ‘safe in our hands’—see N. Timmins, The Five Giants: A Biography of the Welfare State (London: Harper Collins, 1995), 393. 32. J. van der Zee and M. Kroneman, ‘Bismarck or Beveridge: A Beauty Contest between Dinosaurs’, BMC Health Services Research, 7 (94) (2007), available at http://www.ncbi.nlm. nih.gov/pmc/articles/PMC1934356/, accessed 16 March 2011. 33. Thomas McKeown, The Modern Rise of Population (London: Edward Arnold, 1976). 34. J. P. Bunker, H. S. Frazier, and F. Mosteller, ‘Improving Health: Measuring Effects of Medical Care’, Milbank Quarterly, 72 (1994), 225–58. 35. E. Nolte and C. M. McKee, ‘Measuring the Health of Nations’, Health Affairs, 27 (2008), 58–71 (see Figure 3), include bacterial infections, treatable cancers, diabetes, cardiovascular and cerebrovascular disease, complications of common surgical procedures, and a proportion of deaths from ischaemic heart disease (to exclude the impact of preventive anti-smoking policies).

Select Bibliography Anderson, Odin, Health Care: Can There Be Equity? The United States, Sweden and England (New York: Wiley, 1972). Campbell, John Creighton, and Naoki Ikegami, The Art of Balance in Health Policy: Maintaining Japan’s Low-Cost, Egalitarian System (Cambridge: Cambridge University Press, 1998). Dutton, Paul, Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France (Ithaca: Cornell University Press, 2007). Esping-Andersen, Gøsta, The Three Worlds of Welfare Capitalism (Cambridge: Polity Press, 1990). Harris, Bernard, The Origins of the British Welfare State: Social Welfare in England and Wales, 1800–1945 (Basingstoke: Palgrave Macmillan, 2004). Immergut, Ellen, Health Politics: Interests and Institutions in Western Europe (Cambridge: Cambridge University Press, 1992). Knox, Richard, Germany’s Health System: One Nation, United with Health Care for All (New York: Faulkner and Gray, 1993). Light, Donald, and Alexander Schuller (eds), Political Values and Health Care: The German Experience (London: MIT Press, 1986). van der Linden, Marcel (ed.), Social Security Mutualism: The Comparative History of Mutual Benefit Societies (Bern: Peter Lang, 1996). Murray, John, Origins of American Health Insurance (London: Yale University Press, 2007). Powell, Margaret, and Masahira Anesaki, Health Care in Japan (London: Routledge, 1990).

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Roemer, Milton, National Health Systems of the World, vol. I: The Countries (Oxford: Oxford University Press, 1991). Skocpol, Theda, Boomerang: Clinton’s Health Security Effort and the Turn against Government in U.S. Politics (New York: Norton, 1996). Starr, Paul, The Social Transformation of American Medicine (New York: Basic Books, 1982). Webster, Charles, The National Health Service: A Political History (Oxford: Oxford University Press, 2nd edn, 2002).

chapter 25

hea lth, wor k, a n d en v ironm en t: a hippocr atic tu r n in m edica l history c hristopher s ellers

Twenty-five years ago, those health historians whose eyes roved outside those most recognizably medical of places—the clinic, the laboratory, and the hospital—thought of their subject as ‘public health’. Mostly, they looked at cities, or on a smaller scale, the home and the factory. Many of them also embraced the social-historical project of writing medical history more ‘from the bottom up’, through the eyes of the in-expert. Fastforward a quarter of a century, and these efforts have amounted to something more: a revival of Hippocratic ways of thinking in medical and health history. Medical thinking about airs, waters, and places has attracted new scrutiny from historians; so too, built environments, pollution, and other influences on health across city and countryside.1 For some historians who take health questions seriously, that former centrality of medical places has even been flipped on its head, as more or less un-medicalized environments and exposures have taken centre stage. The changing ways in which human surroundings interact with human bodies, or are imagined to, have yielded some of the field’s most innovative and invigorating scholarship. These developments reflect trends in health and medicine from the late twentieth into the early twenty-first centuries. Within developed world nations, the ever-growing share of mortality from chronic degenerative diseases, whose extra-bodily causes have been so difficult to track and prove, posed severe challenges both to doctors and to public health establishments. In response, the rise of ‘risk factor’ medicine opened the door to new preventive mindsets among many doctors, focused on exposures faced by patients beyond the confines of the clinic.2 Eroding many of the pre-established boundaries between clinical medicine and public health, new understandings as well as uncertainties about the causes of many diseases also spurred vast new health-related interventions

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of the state in consumer markets and the environment. Among those movements that since the 1960s and 1970s have actively redrawn efforts to oversee and regulate the health of nations, environmentalism has had a special impact on the field’s Hippocratic turn. From its targeting of contaminants in air, water, food, and land, to more recent dilemmas over endocrine inhibitors and global warming, the environmental movement has energized greater attentiveness to how people’s surroundings may influence their health. Medical geography has seen a revival, as well, via new technologies for digitalizing geographic information that have coincided with interests in mapping out all manner of differences, whether in disease rates or medical services. Globalization has further augmented a need within the health professions to understand how dramatically health and medicine may differ by place, both between and within nations. For all these reasons, health professionals have continued to join with similar-minded counterparts in other fields to expand the study and remedy of the bodily impacts of those airs, waters, and places identified millennia ago by Hippocrates as central determinants of people’s health and well-being. Intellectually, trends within the academic sphere of history and related fields have also aided medical historians’ efforts to resuscitate the historical significance of environment and place. Early influential work, like that of Michel Foucault, emphasizing how architecture could mould discursive and intellectual shifts, has encouraged growing attention to the role of buildings and space in the history of science and medicine. The rise of environmental history has spawned new ways of writing environments and ecological dynamics themselves into history, but approaching it from unaccustomed angles.3 New emphases on space within urban history, what some have described as a ‘spatial turn’ in other historical fields, as well as a return to favour of the professional field of geographers in the academy, have forged further tools. Expanding on the insights of phenomenologists like Merleau Ponty, scholarship on ‘the body’ and embodiment has yielded a wealth of other new approaches to the experience of illhealth, at once sensory and situated.4 As important is precisely how new-found emphases on the cultural and concrete particularity of places have unfolded out of a central underlying tension in the social history of medicine itself. Ever since its mid-twentieth-century inception, this field has sought to widen its understanding of medicine to include ‘the social’ and experiences ‘from the bottom up’. As it has delved more deeply into the categories and viewpoints of the inexpert, the latter effort especially has made plain the underlying dependence of much social history of medicine on medical categories, such as ‘disease’ and ‘patients’, forged in medicalized places. However, those categories by which the in-expert contended with their health, we are finding, did not as easily shear away neo-Hippocratic ideas and emphases—on airs, waters, and places—as historians revealed late-nineteenth-century health professionals to have done. And for some historians who have shifted their own frameworks in Hippocratic directions, the project of a social history of medicine has itself come to look very different, more like a health history of particular places, or of ‘place’ itself. We are discovering a multitude of non-medicalized arenas that have raised health-related questions, where the expertise of non-medical experts has vied with that

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of medical ones, and where the knowledge claims of the in-expert plausibly could look equally or even more persuasive, in retrospect, than those of the formally trained. An exhaustive account of all these trends is beyond the scope of this chapter. I concentrate on a few representative areas where this intermeshing of socio-cultural with Hippocratic history has proven especially fruitful, mostly in nineteenth- and twentiethcentury histories of the United States and Britain. I begin with the changing consideration of industrial health history, as a telling case in point.

The crucible of the workplace: new histories of industrial health The founding moments in the modern writing of industrial health history came in the early twentieth century in Britain and in the mid-twentieth century in the United States, coincident with the founding of the social history of medicine itself.5 These authors, many of them practitioners and/or activists, drew upon broad if vague narratives of industrialization, conceived as fundamentally Western and modern in nature. Even as these scholars drew attention to the peculiar dangers associated with industrial development, they highlighted the modernity and progress of reform and those remedies of science, law, and profession that they themselves had often helped apply to industrial hazards. Teleky, for instance, tallied a smooth progress of national achievements around the Western world in the achievement of regulatory laws, agencies, and professional groups.6 Thin accounts of industrial change accompanied minimal inquiry into the variety of perspectives and influences outside expert communities. Both unions and employer groups remained largely off-stage; workers’ pathologies stayed front and centre, but largely as seen through the eyes of health and hygiene professionals. The revival of industrial hazard history in the late twentieth century by social historians of medicine took up many of those dimensions missing from or sidelined in this earlier literature. Sparked by edited collections by Weindling and by Rosner and Markowitz, recent scholarship has integrated our understanding of occupational health with the new social and political history of the past three decades.7 One theme playing a prominent, if varied, role in subsequent work is that of the influence of corporate interests on doctors and other experts in industrial health, as well as on legal and regulatory solutions to health problems. Since the scholarship of the 1970s, it has become widely recognized, as emphasized by Alan Dembe and others, that occupational health issues are among the most obviously ‘social’ in medicine as a whole, riven by biases of economic interest, as well as by imbalances of power and resources that favour managers and their corporate employers.8 Where historians have differed is in just how and where to interpret the presence of biases toward owners and managers. For instance, some early social historians of industrial health, wary of experts’ considerable power, tended to equate the achievement of scientific legitimacy itself with

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corporate victory.9 Generally, however, many subsequent histories have revolved around what we might term recognition narratives: just when work-related diseases came to be recognized, where, how, and by whom. While seeing many doctors and other experts as corporate allies, authors of these recognition stories have also singled out other experts whom they find more worker-friendly.10 So too with interventions by the state: those same agencies or strategies that some authors treat as progressive accomplishments, others see as conceding too much to corporations. Glaring divides between differing historical approaches are readily evident in the history of asbestosrelated disease, now probably the most widely studied of historical industrial pathologies. Much work has considered asbestos studies over the mid-twentieth century, in the United States, Britain, and other industrial nations, as exemplifying corporate abuse of industrial health science.11 Others have argued that the industry and its scientific allies have been improperly maligned through retrospect, even that the rising use of asbestos as a fire retardant over the mid-twentieth century saved lives.12 Such stark divides, and the potential ramifications of this history for contemporary litigation, have elevated issues that in other fields of medical history might seem picayune into matters of intense debate. The medical education of leading mid-century asbestos researcher Irving Selikoff (1915–92), for instance, sparked a slew of recent articles and letters to the editor.13 Taking a different tack, some have also tracked the historicity and changing terms of ‘objectivity’ itself in industrial medicine, in response to shifting fronts of partisan clashes.14 For all these differing emphases and discord, some striking agreements run through much of this new history of industrial health. One of these is about the importance of worker groups and agency in industrial health history. From the work of Rosner and Markowitz to Derickson in the United States, from that of Johnston and McIvor to Melling and Bufton in the United Kingdom, scholars have time after time demonstrated the impact of labour movements on disease recognition as well as occupational health reform. Less thematized and more covertly, especially from the 1920s and 1930s onwards, many of these histories reveal a reliance of labour activism itself on those with at least some foothold in expert communities.15 These complexities have yielded an additional, broad conclusion: the interests embodied by a given industrial hazard regime no longer seem as easily discernible or self-evident. Instead, they demand empirical inquiry. By the same token, at least in societies where market capitalism is dominant, the degree to which industrialists can impose hazards on their workforce and forestall or co-opt state interventions seems highly contingent. Industrial health reform itself seems much less impelled by ‘progress’, more by struggle and conflict. Reform is a politically charged outcome of decisions and battles pursued by multiple groups over the existence and severity of hazards as well as the kind and degree of control warranted. If a more searching quest for cross-national generalizations and comparisons has only just begun, the new social history of industrial health has already yielded a more realistic and durable if messier understanding of the many changes, conditions, and influences affecting industrial hazards and their control. That fuller range of social and political contexts and contingencies we now know to have shaped the recognition and control of these hazards has

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brought new depth and realism to our understanding of the health history of industrial workplaces. Among the less considered topics for study are those occupational hazards that are avowedly mental, or that straddle hotly debated boundaries between the physiological and psychological. A few studies have looked at industrial fatigue, a popular concept in early-twentieth-century British and US medicine, as a successor to ‘nervous’ and ‘neurasthenic’ ailments defined in the nineteenth century. Some studies suggest fatigue to have then taken a backseat to chemically and physically defined threats. However, the long legacy of a famous ‘Hawthorne experiment’ of the 1920s, along with more recently recognized phenomena such as stress and ‘sick building syndrome’, explored by Michelle Murphy and others, point to less explored continuities as well. It may well be that the uncertainties stirred by late-twentieth-century sciences such as toxicology have opened up entire other realms of ailments defying resolution into the physiological or the psychosomatic.16 A most significant recent development is the growing attention to industrial hazard history among historians who study workplaces outside the most industrialized, and most studied, of nations. In addition to well-established bodies of literature on the United States, Britain, and Germany, we have begun to learn much about industrial hazards in other European nations.17 Potentially more transformative of our understanding are the emerging studies of industrial hazards in what, over the twentieth century, became known as the developing world. While important studies by anthropologists, sociologists, and geographers have looked at industrial hazards and disasters of recent decades outside the developed world, historians have recently begun to join them.18 Joining isolated earlier studies such as that of Packard, historians have explored occupational hazards and their politics in nations such as Mexico, Chile, Malaysia, and South Africa.19 These studies, as well as Tweedale and McCulloch’s recent history of Turner and Newall, the asbestos multinational, are opening the door to comparisons between industrial hazards in developing and those in developed nations.20 Developing world studies suggest the occupational importance not just of the ‘industrial’ exposures that have dominated their developed-nation counterparts, from dust or heavy metals or toxins, but from infectious diseases. In the oil fields of Mexico or the jungles of Malaysia, dangers like malaria mosquitoes were among the most significant for those sent to labour in the countryside. Often, tools and remedies devised in the more developed nations neglected these hazards, or assumed traditional urban public health departments would oversee them. These studies, as well, point to the importance of occupational hazards both before and after a nation or territory acquired industrial factories. Clearly the countryside could be as susceptible as any factory town or city to occupational hazards.21 Assertions and conclusions about worker influence on the outcome of struggles over occupational health have helped generate greater interest in just how workers themselves perceived and experienced these ailments. Our sense of workers’ perspectives on hazardous work is becoming ever more robust and elaborate through the adoption of a variety of new methods and terms of analysis. An emphasis on gender

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and other differences within workforces has uncovered the contrasted experiences with industrial hazards among women workers.22 So too has gender analysis yielded new insights into notions of masculinity and the ways it governs how male workers might choose or justify, as well as combat, workplace risks. The work of Johnston and McIvor, in particular, has advanced the study of masculinity in the history of industrial hazard, in particular, through a tool that promises much further understanding of worker encounters with hazards, at least over the preceding half-century: oral history.23 The method yields a parallel yet ultimately separate trajectory and set of concerns and categories by which workers themselves confronted occupational hazards—not just as victims, nor as expert knowers, yet still through a knowledge, interpretative activity and agency of their own. And here, as historians of occupational health have absorbed or adapted the tools of cultural history, they have discovered worker voices in debates over industrial health that can defy the expectations of the recognition narrative. Not only may workers not always embrace knowledge or remedies of hazards; they may also disagree with one another, and not always see eye to eye even with the most labour-friendly of experts. These developments have paralleled and nourished new efforts to re-conceive labour history itself as revolving around ‘workers’ bodies’. Though many labour historians calling for such a focus have preferred to emphasize issues of gender and race over questions about health, this agenda of an embodied history of workers is opening up fruitful terrain for medical historians.24 One promising pathway has come in the scholarly development of disability studies. Critiquing much preceding history of occupational health as focused more on policy issues of workplace regulation than on the lived experience of workers, disability historians seek to centre their work around what it was like to live as injured or impaired, deprived of an able body.25 Disabilities suffered as a result of occupation has been a central topic in this work. Disability experiences yield many of the same strengths as does the emphasis on ‘the body’ called for by other labour historians: a holistic effort to sort out the full consequences of workplaces and their effects, stretching across individual lives. It also offers an avenue into histories of workplace health and medicine that revolve less centrally around medical concepts like disease and that offer historians at least a chance of drawing nearer to fathoming and charting workers’ own historical experiences. Seen from another angle, however, this ‘body’ focus of worker history artificially severs ‘the body’ from its physical surroundings, in as complete a manner as modern medicine—and its historians—have done. And yet, as Kasson has noted, workers themselves moved through a variety of places, each with bodily relevance.26 Some place-attentive scholarship in industrial hazard history has led in a similar direction, by examining the material connections between threats inside the workplace and those imposed beyond. From pollution to consumer products, from asbestos to lead, many industries imposing dangers to their workers also threatened the health of those beyond their factory walls, via the same or similar substances. A recent efflorescence of histories has explored ways of writing these broader environmental concerns into medical and health history.

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Urban airs and waters: the streaming of pathogens and poisons In the ways in which they have sought to tackle the germs, pollutants, and other dangers that travel, conveyed by Hippocrates’ air and water, as well as through the land itself, new historians of environmental health have developed quite different versions of what an earlier generation termed ‘history of public health’. Historians writing those fielddefining histories of public health over the 1950s into the 1970s centred them primarily around the agendas of urban or state health departments occupied with industrial problems.27 More recently, health historians have been joined by many others interested in issues of urban health: environmental and urban historians, as well as cultural historians and historical geographers. This scholarship, like that of industrial health history, has unpacked a widening range of political, social, and economic interests in the health history of urban places. As with the new histories of industrial health reform, the progress of urban health reform has come to seem less inevitable and ever more contingent on a diversity of groups, perceptions, and clashes. One theme that has stood out in this urban scholarship, more so than in its workplace-focused counterparts, concerns the ecological complexity of the places that health reformers confronted and sought to ameliorate. Not so paradoxically, the very mobility of pollutants themselves, their defiance of neighbourhood or city boundaries, has helped lead historians to an ever-more searching scrutiny of geographic differences in the urban experience of disease and health. Changing approaches to the history of urban health have also been influenced by the relatively new field of environmental history. As environmental history has emerged and matured over the past three decades, first in the United States and more recently in Europe and elsewhere, its efforts to plumb ‘the role and place of nature in history’ have forged powerful tools for reconnecting the indoor history of disciplinary spaces like the factory to their broader material surrounds. Where environmental historians have long parted ways with many trained in the history of medicine and science is in their interest in, and willingness to apply, methods of ecology and other recent natural sciences to understanding of human pasts. Environmental history shares with medical history a familiar tradition of projecting today’s epidemiology and disease ecology onto the past; indeed, writings of early innovators, like Crosby and McNeill, about epidemics of infectious disease were widely read in both fields. Newer approaches to urban and industrial environments, spotlighting those material flows and processes that many social and cultural historians are apt to neglect, remain less well known to medical historians. These histories focus on material streams through the heart of modern industrial and postindustrial societies. They offer models for re-centring health history beyond public health departments and their agendas, as well as medical places and gazes: on material flows, from commodities to sewage to industrial and consumer by-products, to those more obscure and natural processes that have not always fallen within the analytic domain of human culture. While some have also envisioned a historical ecology of the

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workplace,28 more influential have been the approaches of environmental historians to that central place of public health history, the city. In the earlier literature, questions of infrastructure and service provision stood front and centre. While Tarr’s path-breaking work looked at the construction of water supplies and sewers, Melosi explored garbage collection and other ‘sanitary’ services, culminating in his definitive survey of the making of a ‘sanitary city’ in the United States.29 More recently, new fusions of social and environmental history, inspired by the upsurge of an environmental justice movement drawing attention to environmental inequities, have scrutinized how and why some neighbourhoods and communities have borne more of the brunt of wastes or industrial siting or environmental neglect than others. An immense portion of this new scholarship homes in on a finer grain of urban geography: on the differential experiences of neighbourhoods within the city itself. An early model for this approach was Hurley’s Environmental Inequalities, which recounted the differential exposures and clashes over pollution between blacks and middle- and working-class whites in post-Second World War Gary, Indiana, home of a steel plant.30 A growing number of historians, largely working in the United States, have recounted similar histories, with many additional twists, across time and place. The variegated residential geography of cities has itself become a major theme of new fusionist combinations of environmental and social history, nearly always with an eye to perceived or actual implications for health. Methods vary. Some revolve around particular neighbourhoods that bore the brunt of the most noxious land uses, such as Washington’s Packing Them In. Others such as Pellow’s Garbage Wars follow the distribution and politics of garbage or other hazard across a city. Still others consider the differential distribution of urban health hazards within larger industrial ecologies, whether via Platt’s comparison between the industrializing metropolises of Chicago and Manchester or the Colorado cities of Andrews’s Killing for Coal. Other recent approaches pay special heed to cultural categories and representations.31 What defines these, as so many other studies in the burgeoning scholarship devoted to questions of urban health—socio-cultural, geographic, and ecological—is the mobility of real or potential health hazards. The result of industry or other activity, whose benefits may be narrowly confined or widespread, the movement of hazards enables what the geographer David Harvey has termed a ‘spatial fix’.32 More vocal and powerful groups are often able to keep impacts away from where they live, work, and play; other groups and places then bear the health and other burdens. As we are learning, this tendency of confining risks to the least privileged corners of a city or nation— and more recently, to the least developed corners of the world—has a dynamic historicity. Too-narrow notions of public health and medical history have left this kind of historical investigation mainly to environmental and urban historians, yet from Hurley onwards it has added much to our understanding of the historical relationship between environments and health, whether more or less directly. Among its findings, some of the best of this work recounts an evolving narrowness within health professions from the late nineteenth into the twentieth century. Issues from urban planning to garbage disposal that earlier had been considered matters of ‘health’ were

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de-medicalized, taken up, instead, by professionals who no longer thought or spoke in terms of ‘disease’ or ‘health’. Self-identified public health and medical historians have found common ground with these approaches, especially in unpacking the exercises of power and injustice that accompanied the making of bacteriology-based public health. Recent works on California’s major cities are illustrative. Molina’s study of racialization in public health policies in Los Angeles and Shah’s studies of how race figured into the politics of public health in San Francisco emphasize the role of bacteriology-based policies in reinforcing racial thinking as well as residential segregation within early-twentieth-century cities. Also through a study of San Francisco, the medical geographer Craddock has offered a more sweeping overview of how categories of gender and poverty, as well, have shaped that city’s public health policies and debates, through the AIDS epidemic of recent times. Nor has contributing work been confined to scholarship focusing centrally on epidemics or germs alone. For instance, studies as diverse as Deverell’s history of a ‘Mexican Past’ in Los Angeles and Davis’s study of key episodes in Los Angeles’ confrontations with ecological disaster include important chapters on that city’s plague epidemic in the 1920s.33 Another way in which environmental historians of the city have opened up new terrain in medical and health history is through studies framed around ‘air’ or ‘water pollution’, those media by which toxins as well as particulates and pathogens often spread. Path-breaking historians who took up the study of pollution from the 1980s—Tarr and Melosi in the United States, Brimblecombe and Luckin in the United Kingdom—mainly looked at its aqueous variants.34 More recently, environmental historians such as Dewey, Stradling, Mosley, and Thorsheim have homed in on air, from the ‘smog’, increasingly regarded as a major public health problem during the 1940s through the 1960s to the ‘smoke’ and ‘fumes’ of late-nineteenth- and early-twentieth-century industrial cities and factories.35 Much early work by environmental historians concentrated on its regulatory politics; increasingly, they have turned to the various groups and politics that disagreed and clashed over what should be done. With this last turn, more common ground has opened up between public health and environmental historians. One urban toxin has already received considerable attention, the heavy metal lead. Health historians Warren and Fee have explored how urban lead’s domestic presence first became recognized as a public health problem during the 1920s and 1930s in cities such as Baltimore.36 Medical forays into victims’ homes did not initially entertain any contribution from leaded household fumes or dust; the working assumption was that fulminant lead poisoning turning up in children came from chewing on lead-painted cribs and toys. But already, the spread of lead via consumer products from storage batteries to leaded gasoline was resulting in new patterns of accumulation and exposure, which helped encourage medical and public health commentators to revise their ideas about lead during the post-Second World War period. Pioneering work by Warren and Fee as well as Corn, English, Burnham, and Rosner and Markowitz has elucidated the mounting post-Second World War campaigns of public health officials against childhood lead poisoning, as well as lead in gasoline.37 Similar toxin-centred studies are also under way

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on other toxins. A 2008 special issue of Environmental History highlights much of this new work, on contaminants from mercury to Bis-phenol A to endocrine receptors.38 Of course, these toxin-centred approaches may not be centred on any particular place at all. Indeed, one of the virtues of centring histories around such hazards themselves is that historians are thereby freed to follow historical exposures across a multitude of locales.

Generalizing the Hippocratic: sciences, diseases, and the hundred-year hiatus Converging programmes in environmental and health and medical history have also forged less place-specific approaches. Hippocrates’ own tract on Airs, Waters and Places itself was meant to apply generally, across many locales. So too with the frameworks being forged in recent histories that have helped usher in this Hippocratic turn in our understanding of medical pasts. While some may focus on cities or factories, others concentrate on particular sciences or diseases. This literature, in combination with that above, has broad implications. It is yielding a fundamental re-shaping of our metanarrative about what has long been called the history of public health. Already by the early 1990s, medical and health historians had agreed that extra-bodily or environmental terms and categories retained a marked prominence especially into early- to mid-nineteenth-century sciences of medicine. Duden identified a medieval sense of correspondence between bodily and cosmological events among the patients of a German doctor familiar with emerging anatomical accounts of disease. Corbin’s work on odour, for instance, showed the continuing importance of the atmosphere, soils, and stenches even far into the nineteenth century for French doctors and public health officials, while Warner’s account of mid-nineteenth-century American medicine emphasized its fascination with geographic and climatological factors that defined a local and regional nature for diseases.39 More recently, our understanding of and appreciation for this ‘older’ way of thinking has been considerably deepened, in part through probing that extends beyond the purviews only of healers and the diseased. Conevery Bolton Valencius, in particular, has explored how, in the nineteenth century, US frontier and agricultural land was considered in terms of health or ‘salubriousness’ as well as sickness.40 At the same time, Harrison, Anderson, and others have also brought out a continuing centrality of environmental concepts like acclimatization in the field of colonial medicine.41 For the twentieth century, those scientific disciplines and understandings that encouraged renewed attention to the health impacts of place have also garnered growing interest from historians of health and medicine. The genesis of ‘risk factor’ medicine during the twentieth century has been described by Rothstein as an ‘uneven revolution’. A recent history of the Framingham study of factors in heart disease, conducted by federally funded investigators over the middle decades of the twentieth

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century, has fleshed out its importance to this revolution.42 So too, mounting post-war studies of smoking, which provided a gold standard for a new epidemiology of ‘lifestyle’ factors, have received an increasing share of attention from historians, most recently in Brandt’s monumental work The Cigarette Century. Despite some attention to key figures such as Wilhelm Hueper (d. 1977), director of an environmental health unit at the National Cancer Institute during the early post-Second World War decades, there has been less study of how, in the efflorescence of chronic disease epidemiology, the study of more inadvertent environmental exposures vied with those of smoking or other consumer choices.43 Where we have learned more about the new environmental epidemiology and its impacts over the past few decades has been in the study of exposures among those living in the vicinity of hazardous production, whether inside cities or without. Arguably, from recent examples of Bhophal and Chernobyl, these kinds of exposures have taken precedence in the past few decades over those confined to workplace interiors. Following the lead of sociologists such as Brown, but also consistent with other historiographic trends such as that in the history of industrial health, much of this work seeks to unpack the controversies that catalyse and confound this science and also helped to define its impacts.44 Among the themes that unite much of this scholarship are the divides between how local residents and scientists, especially epidemiologists, saw these hazards, including their differing approaches to uncertainty. This literature suggests how, on some fronts, knowledge claims of locals may themselves deserve as much attention to their truth value as those of epidemiologists who gather statistics on environmental causality.45 Another science that has received historical attention is the more laboratory-based discipline of toxicology. After a first wave of attention from Dunlap, Whorton, and others in the 1980s, we are seeing the blossoming of new studies of environmental toxicology and its origins and impacts, including several dissertations and recent books. Daniel’s Toxic Drift uncovers the controversies over spraying of DDT that culminated in an early lawsuit against usage of the substance by an Alabama farmer. Frickel has studied the emergence and professionalization of the toxicology field after the Second World War and Nash has provided a provocative new perspective on just what the toxicology of the post-war period could and could not do to take environmental effects into account.46 It is no accident that pesticides have figured heavily in this literature. In the post-war period, they provided arguably the most telling litmus test within debates between older public health and newer environmental health experts.47 Prominent institutions, such as the US Public Health Service and their public health allies, embraced DDT and other pesticides as a ‘cure’ for malaria. However, others, notably the Fish and Wildlife Service and the Food and Drug Administration, joined forces with biologists and physicians in arguing that these substances posed new and under-recognized threats. These new scientific advocates arguably belong within the penumbra of health history. If they opposed much of the era’s public health expertise, both they and the new laws and agencies their science supported were forging new environmental and ecological perspectives on human health.

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One additional way that medical and health historians have begun to absorb rising emphases on the environmental and geographic dimensions of health is through study of those diseases that have figured prominently in latter-day shifts in medical thinking. On the infectious disease front, malaria has been a subject of studies, such as those by Packard and Humphreys, emphasizing the importance not just of social differences but ecological ones in the upsurge of this disease across time and place.48 Cancer was an early disease that attracted emphasis on its environmental causation. From Patterson to Proctor, the post-Second World War surge of attention to environmental factors in cancer has received a good deal of attention.49 More recently, allergy and asthma, diseases essentially defined as environmental, have been the focus of fine studies by Jackson, Mitman, and Keirns.50 Some of this scholarship situates the understanding of these diseases as ‘environmental’ in a long tradition of ‘diseases of civilization’, thereby emphasizing a continuity in medical history. As social and cultural historians of medicine have shown, this category itself has a long history reaching far back before the nineteenth century.51 Diseasecentred histories of those chronic ailments around which risk-factor science flourished have scrutinized just how and why this older diseases of civilization tradition came to be revived in confrontation with the chemical and physical risks of more recent times. In his history of Cancer Wars, Proctor, for instance, suggests how political pressures on medical and scientific institutions may encourage, but also suppress, study of cancer’s environmental dimensions, thereby shaping the contours of what is known, but also unknown.52 Among the new studies of asthma and allergic ailments, Jackson’s Allergy: The History of a Modern Malady situates the history of allergy within that longer ‘diseases of civilization’ tradition, while also attending carefully to departures that were involved. Jackson, Proctor, and other authors have thereby yielded new questions, also, about discontinuities with past medical thinking, in particular what we may, in retrospect, now interpret as a century-long hiatus in Hippocratic thinking. Already by the 1980s, historians of public health were writing about a ‘narrowing’ thesis, arguing that Western medical thought of the late nineteenth and early twentieth centuries had, in modernizing, cast out environmental explanations and interventions against disease. With the rise of modern public health, germ theories of disease drove out all contenders, shifting hygienic focus away from environmental vagaries like miasma because these failed to pass clinical and laboratory tests. Now, with the deepening understanding of that earlier era’s reliance on geography, miasma ‘theory’, and other neoHippocratic talk, we have gained a better appreciation of what was lost. Recent authors such as Mitman and Nash go beyond earlier statements of ‘narrowing’, to bemoan not just a loss of perspectival breadth, but of the social and ecological realities of disease. For Mitman, the real socio-environmental roots of a disease like asthma thereby become increasingly easy to ignore, as therapies like inhalers, yielding pharmaceutical profits, come to be favoured. Moreover, as Nash shows, once historians look for them, environmentally centred notions about health could not help but persist even within medicine and public health, albeit with reduced visibility and status. Sanitary

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engineers as well as medical entomologists had to ask and answer many ecological questions.53 Whatever their arguments about this period of hiatus, historians are coming to appreciate ever more how, when she published Silent Spring in 1962, Rachel Carson was broaching questions and issues that had not entirely vanished from everyone’s vision. The culpability lay, instead, in the narrowed vision of public health authorities, who themselves sprayed insect vectors ‘indiscriminately’ with DDT, and industrial toxicologists and doctors, including US Public Health Service officials, who swore to convictions about DDT’s harmlessness. Acknowledging the long-ignored importance of someone such as Carson to the history of health and medicine means more than just providing historical perspective on these half-century-old battles themselves. More broadly, it also signals a heightened appreciation of the historicity of how boundaries between the human body and its surroundings have been perceived. While nods to Rachel Carson and ‘ecology’ provide convenient reference points for these challenges, the implications went deeper than the influence of any individual or toxin or discipline. The bodily boundaries of the ‘pathological’ had commenced that long, slow dissolution so characteristic of our postmodern age. And as they continued to dissolve, those customary jurisdictional boundaries separating medicine from public health, and both from the environmental disciplines, also often failed to hold. As seemingly settled boundaries between disciplinary realms have been challenged and redrawn, all the way up to the present, links between environment and health keep bursting out of rarefied professional discussions, to become matters of lay conviction and public and legislative debate.

Conclusion No doubt vast and powerful segments of medicine and public health will continue to chug along without so much as a mention of Hippocrates, disregarding how many ecological, environmental, and geographic questions have become bound up with those of health. So too many medical historians. But this Hippocratic turn has indeed opened up abundant terrain for those who would follow it. With it has emerged the prospect for a broadened array of topics, methods, and places, not so rigidly defined by the customary professional boundaries and spaces of medicine, or even of public health. Instead, possibilities have opened for new fusions between medical, socio-cultural, and environmental histories of particular places, whether workplace or home, city or countryside, and also of the material and cultural traffic between places. We might term these Hippocratic histories, centred less around classically ‘medical’ places, such as clinics, hospitals, and laboratories, than around those airs, waters, and places that envelop them. One consequence of this Hippocratic turn has been a greater appreciation of the importance to health history of those many experts whom medical and public health

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historians have long ignored: from industrial hygienists and sanitary engineers to entomologists, geochemists, and ecologists. Arguably a still bigger consequence is the deepening appreciation and study it enables of non-expert ways of seeing and experiencing health, even in the most modern of historical eras. Indeed, when it comes to the health implications of airs, waters, and places, the track record of medical expertise, laced as it has been with uncertainty and even error, retains a distinct kinship with the all-toofallible knowledge claims of lay people. Indeed, at significant moments in this history, lay environmental worries have proven more right than expert reassurances. As the next stage in what we have long known as the social history of medicine, we may well look forward to a health history of places, on the one hand, and on the other, an ecological history of the human body.

Notes 1. Gregg Mitman, Michelle Murphy, and Christopher Sellers (eds), Landscapes of Exposure: Knowledge and Illness in Modern Environments, Osiris, special issue, 19 (2004); Conevery Bolton Valencius, ‘Histories of Medical Geography’, Medical History, Supplement 20 (2000), 3–28. 2. William G. Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution (Rochester, NY: University of Rochester Press, 2008). 3. Gregg Mitman, ‘In Search of Health: Landscape and Disease in American Environmental History’, Environmental History, 10 (2005), 184–210. 4. Diarmid A. Finnegan, ‘The Spatial Turn: Geographical Approaches in the History of Science’, Journal of the History of Biology, 41 (2) (2008), 369–88; Anne Buttimer, ‘Airs, Waters, Places: Perennial Puzzles of Health and Environment’, Medical History, Supplement 20 (2000), 211–16; Christopher Sellers, ‘Thoreau’s Body: Towards an Embodied Environmental History’, Environmental History, 4 (4) (1999), 486–514; Joy Parr, ‘Smells Like? Sources of Uncertainty in the History of the Great Lakes Environment’, Environmental History, 11 (2) (2006), 269–99. 5. Thomas Morison Legge, Shaw Lectures on Thirty Years’ Experience of Industrial Maladies: Delivered before the Royal Society of Arts, February and March, 1929 (London: Royal Society of Arts, 1929); R. S. F. Schilling, A Challenging Life: Sixty Years in Occupational Health (London: Canning Press, 1998); George Rosen, The History of Miners’ Diseases: A Medical and Social Interpretation, (New York: Schuman, 1943); Ludwig Teleky, History of Factory and Mine Hygiene (New York: Columbia University Press, 1948). 6. Teleky, History of Factory and Mine Hygiene. 7. Paul Weindling (ed.), The Social History of Occupational Health (London: Croom Helm, 1985); David Rosner and Gerald Markowitz (eds), Dying for Work: Workers’ Safety and Health in Twentieth-Century America (Bloomington: Indiana University Press, 1987). 8. Allard E. Dembe, Occupation and Disease: How Social Factors Affect the Conception of Work-Related Disorders (New Haven, CT: Yale University Press, 1996). 9. Ronald Bayer, The Health and Safety of Workers: Case Studies in the Politics of Professional Responsibility (New York: Oxford University Press, 1988). 10. David Rosner and Gerald E. Markowitz, Deadly Dust: Silicosis and the Politics of Occupational Disease in Twentieth-Century America (Princeton, NJ: Princeton

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17.

18.

christopher sellers University Press, 1991); Alan Derickson, Black Lung: Anatomy of a Public Health Disaster (Ithaca, NY: Cornell University Press, 1998); Claudia Clark, Radium Girls, Women and Industrial Health Reform: 1910–1935 (Chapel Hill: University of North Carolina Press, 1997). Ronald Johnston and Arthur J. McIvor, Lethal Work: A History of the Asbestos Tragedy in Scotland (East Linton: Tuckwell, 2000); Jock McCulloch, Asbestos Blues: Labour, Capital, Physicians and the State in South Africa (Bloomington: Indiana University Press, 2002); Geoffrey Tweedale, Magic Mineral to Killer Dust: Turner and Newall and the Asbestos Hazard (Oxford: Oxford University Press, 2001); Barry I. Castleman, Asbestos: Medical and Legal Aspects (New York: Law and Business, 1984). P. W. J. Bartrip, The Way from Dusty Death: Turner and Newall and the Regulation of Occupational Health in the British Asbestos Industry, 1890s–1970 (London: Athlone Press, 2001); Rachel Maines, Asbestos and Fire: Technological Tradeoffs and the Body at Risk (New Brunswick, NJ: Rutgers University Press, 2005). P. W. J. Bartrip, ‘Irving John Selikoff and the Strange Case of the Missing Medical Degrees’, Journal of the History of Medicine and Allied Sciences, 58 (1) (2003), 3–33; Jock McCulloch and Geoffrey Tweedale, ‘Science Is Not Sufficient: Irving J. Selikoff and the Asbestos Tragedy’, New Solutions: A Journal of Environmental and Occupational Health Policy, 17 (4) (2007), 293–310. Christopher Sellers, ‘ “Prejudice That May Cloud the Mentality”: The Making of Modern Objectivity in American Industrial Medicine’, in John W. Ward and Christian Warren (eds), Silent Victories: The History and Practice of Public Health in Twentieth-Century America (Oxford: Oxford University Press, 2007), 230–52. Rosner and Markowitz, Deadly Dust; Derickson, Black Lung; Johnston and McIvor, Lethal Work; Arthur McIvor and Ronald Johnston, Miners’ Lung: A History of Dust Disease in British Coal Mining (Aldershot: Ashgate, 2007); Mark W. Bufton and Joseph Melling, ‘ “A Mere Matter of Rock”: Organized Labour, Scientific Evidence and British Government Schemes for Compensation of Silicosis and Pneumoconiosis among Coal Miners, 1926– 1940’, Medical History, 49 (2) (2005), 155–78. Arthur McIvor, ‘Work and Health, 1880–1914: A Note on a Neglected Interaction’, Journal of the Scottish Labour History Society, 24 (1989), 47–67; Alan Derickson, ‘Physiological Science and Scientific Management in the Progressive Era: Frederic S. Lee and the Committee on Industrial Fatigue’, Business History Review, 68 (4) (1994), 483–514; Michelle Murphy, Sick Building Syndrome and the Problem of Uncertainty: Environmental Politics, Technoscience, and Women Workers (Durham, NC: Duke University Press, 2006); Richard Gillespie, Manufacturing Knowledge: A History of the Hawthorne Experiments (Cambridge: Cambridge University Press, 1993). For further discussion of the history of stress and psychosomatic diseases, see Chapter 29, ‘Medicine and the Mind’, by Rhodri Hayward in this volume. Odette Hardy-Hémery, Eternit et l’amiante, 1922–2000: aux sources du profit, une industrie du risque (Villeneuve d’Ascq: Presses universitaires du Septentrion, 2005); Caroline Moriceau, ‘L’hygiène à la cristallerie de Baccarat dans la seconde moitiè du XIXe siecle: la santè ouvrière au coeur de la gouvernance industrielle’, Mouvement Social, 213 (2005), 53–70. Kim Fortun, Advocacy after Bhopal: Environmentalism, Disaster, New Global Orders (Chicago: University of Chicago Press, 2001); Adriana Petryna, Life Exposed: Biological Citizens after Chernobyl (Princeton, NJ: Princeton University Press, 2002).

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19. Myrna I. Santiago, The Ecology of Oil: Environment, Labor, and the Mexican Revolution, 1900–1938 (Cambridge: Cambridge University Press, 2006); Amarjit Kaur, ‘Indian Labour, Labour Standards, and Workers’ Health in Burma and Malaya, 1900–1940’, Modern Asian Studies, 40 (2) (2006), 425–75; McCulloch, Asbestos Blues; Angela Vergara, ‘The Recognition of Silicosis: Labor Unions and Physicians in the Chilean Copper Industry, 1930s–1960s’, Bulletin of the History of Medicine, 79 (4) (2005), 723–48. 20. Jock McCulloch and Geoffrey Tweedale, Defending the Indefensible: The Global Asbestos Industry and Its Fight for Survival (New York: Oxford University Press, 2008). 21. Kaur, ‘Indian Labour, Labour Standards, and Workers’ Health’; Santiago, The Ecology of Oil. 22. Allison L. Hepler, Women in Labor: Mothers, Medicine, and Occupational Health in the United States, 1890–1980 (Columbus: Ohio State University Press, 2000); Carolyn Malone, Women’s Bodies and Dangerous Trades in England, 1880–1914 (Woodbridge, Suffolk: Boydell Press, 2003). 23. Johnston and McIvor, Lethal Work; McIvor and Johnston, Miners’ Lung; Ronnie Johnston and Arthur McIvor, ‘Oral History, Subjectivity, and Environmental Reality: Occupational Health Histories in Twentieth-Century Scotland’, Osiris, 19 (2004), 234–49. 24. Ava Baron and Eileen Boris, ‘ “The Body” as a Useful Category for Working-Class History’, Labor, 4 (2) (2007), 23–43. 25. Catherine J. Kudlick, ‘Disability History: Why We Need Another “Other”’, American Historical Review, 108 (3) (2003), 763–93; Susan Burch and Ian Sutherland, ‘Who’s Not Here Yet? American Disability History’, Radical History Review, 94 (2006), 127–47; Sarah F. Rose, ‘ “Crippled Hands”: Disability in Labor and Working-Class History’, Labor: Studies in Working Class History of the Americas, 2 (1) (2005), 27–54. 26. John Kasson, ‘Follow the Bodies: Commentary on “The Body” as a Useful Category for Working-Class History’, Labor, 4 (2) (2007), 45–8. 27. George Rosen, A History of Public Health (Baltimore: Johns Hopkins University Press, 1993); John Duffy, A History of Public Health in New York City (New York: Russell Sage Foundation, 1968); Stuart Galishoff, Newark: The Nation’s Unhealthiest City, 1832–1895 (New Brunswick, NJ: Rutgers University Press, 1988); Judith Walzer Leavitt, The Healthiest City: Milwaukee and the Politics of Health Reform (Princeton, NJ: Princeton University Press, 1982). 28. Arthur F. McEvoy, ‘Working Environments: An Ecological Approach to Industrial Health and Safety’, Technology and Culture, 36 (Supplement, 1995), 145–73. 29. Joel A. Tarr, The Search for the Ultimate Sink: Urban Pollution in Historical Perspective (Akron, OH: University of Akron Press, 1996); Martin V. Melosi, Garbage in the Cities: Refuse, Reform, and the Environment: 1880–1980 (College Station, TX: Texas A&M University Press, 1982); idem, The Sanitary City: Environmental Services in Urban America from Colonial Times to the Present (Pittsburgh: University of Pittsburgh Press, 2008); Christine Meisner Rosen and Joel A. Tarr, ‘The Importance of an Urban Perspective in Environmental History’, Journal of Urban History, 20 (3) (1994), 299–310. 30. Andrew Hurley, Environmental Inequalities: Class, Race, and Industrial Pollution in Gary, Indiana, 1945–1980 (Chapel Hill: University of North Carolina Press, 1995). 31. Sylvia Hood Washington, Packing Them In: An Archaeology of Environmental Racism in Chicago, 1865–1954 (Lanham, MD: Lexington Books, 2005); David Naguib Pellow, Garbage Wars: The Struggle for Environmental Justice in Chicago (Cambridge, MA: MIT Press, 2002); Harold L. Platt, Shock Cities: The Environmental Transformation and Reform of

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32. 33.

34.

35.

36.

37.

38.

39.

40.

christopher sellers Manchester and Chicago (Chicago: University of Chicago Press, 2005); Thomas G. Andrews, Killing for Coal: America’s Deadliest Labor War (Cambridge, MA: Harvard University Press, 2008); Matthew W. Klingle, Emerald City: An Environmental History of Seattle (New Haven, CT: Yale University Press, 2007); Julie Sze, Noxious New York: The Racial Politics of Urban Health and Environmental Justice (Cambridge, MA: MIT Press, 2006); Andrew C. Isenberg (ed.), The Nature of Cities (Rochester, NY: University of Rochester Press, 2006); Bruce Stephenson, ‘Urban Environmental History: The Essence of a Contradiction’, Journal of Urban History, 31 (6) (2005), 887–98. David Harvey, ‘The Spatial Fix: Hegel, Von Thunen, and Marx’, Antipode, 13 (3) (1981), 1–12. William Deverell, Whitewashed Adobe: The Rise of Los Angeles and the Remaking of Its Mexican Past (Berkeley: University of California Press, 2005); Mike Davis, Ecology of Fear: Los Angeles and the Imagination of Disaster (London: Vintage, 1999). Tarr, The Search for the Ultimate Sink; Martin V. Melosi, Pollution and Reform in American Cities, 1870–1930 (Austin: University of Texas Press, 1980); Bill Luckin, Pollution and Control: A Social History of the Thames in the Nineteenth Century (Bristol/Boston: Hilger, 1986); Peter Brimblecombe, The Big Smoke: A History of Air Pollution in London since Medieval Times (London: Methuen, 1987). Scott Hamilton Dewey, Don’t Breathe the Air: Air Pollution and U.S. Environmental Politics, 1945–1970 (College Station, TX: Texas A&M University Press, 2000); David Stradling, Smokestacks and Progressives: Environmentalists, Engineers, and Air Quality in America, 1881–1951 (Baltimore: Johns Hopkins University Press, 2002); Stephen Mosley, The Chimney of the World: A History of Smoke Pollution in Victorian and Edwardian Manchester (Cambridge: White Horse Press, 1998); Peter Thorsheim, Inventing Pollution: Coal, Smoke, and Culture in Britain since 1800 (Athens: Ohio University Press, 2006). Christian Warren, Brush with Death: A Social History of Lead Poisoning (Baltimore: Johns Hopkins University Press, 2000); Elizabeth Fee, ‘Public Health in Practice: An Early Confrontation with the “Silent Epidemic” of Childhood Lead Paint Poisoning’, Journal of the History of Medicine and Allied Sciences, 45 (1990), 570–606. Peter C. English, Old Paint: A Medical History of Childhood Lead-Paint Poisoning in the United States to 1980 (New Brunswick, NJ: Rutgers University Press, 2001); John C. Burnham, ‘Unraveling the Mystery of Why There Was No Childhood Lead Poisoning’, Journal of the History of Medicine and Allied Sciences, 60 (4) (2005), 445–77; David Rosner and Gerald Markowitz, Deceit and Denial: The Deadly Politics of Industrial Pollution (Berkeley: University of California Press, 2002). Jody A. Roberts and Nancy Langston, ‘Toxic Bodies/Toxic Environments: An Interdisciplinary Forum’, Environmental History, 13 (4) (October 2008), at: http://www. historycooperative.org.libproxy.cc.stonybrook.edu/journals/eh/13.4/roberts.html, accessed 9 May 2009. Barbara Duden, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany (Cambridge, MA: Harvard University Press, 1998); Alain Corbin, The Foul and the Fragrant: Odor and the French Social Imagination (Cambridge, MA: Harvard University Press, 1988); John Harley Warner, The Therapeutic Perspective (Princeton, NJ: Princeton University Press, 1997). Conevery Bolton Valencius, The Health of the Country: How American Settlers Understood Themselves and Their Land (New York: Basic Books, 2002).

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41. Mark Harrison, Climates and Constitutions: Health, Race, Environment and British Imperialism in India 1600–1850 (Oxford: Oxford University Press, 2000); Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines (Durham, NC: Duke University Press, 2006). 42. Rothstein, Public Health and the Risk Factor; Daniel Levy and Susan Brink, A Change of Heart: How the People of Framingham, Massachusetts, Helped Unravel the Mysteries of Cardiovascular Disease (New York: Knopf, 2005). 43. Allan Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America (New York: Basic Books, 2009); C. Sellers, ‘Discovering Environmental Cancer: Wilhelm Hueper, Post-World War II Epidemiology, and the Vanishing Clinician’s Eye’, American Journal of Public Health, 87 (11) (1997), 1824–35; David Michaels, ‘When Science Isn’t Enough: Wilhelm Hueper, Robert A. M. Case, and the Limits of Scientific Evidence in Preventing Occupational Bladder Cancer’, International Journal of Occupational and Environmental Health, 1 (3) (1995), 278–88; R. N. Proctor, ‘Wilhelm C. Hueper: Pioneer of Environmental Carcinogenesis’, Abhandlungen zur Geschichte der Medizin und der Naturwissenschaften, 81 (1997), 290–305. 44. Phil Brown and Edwin J. Mikkelsen, No Safe Place: Toxic Waste, Leukemia, and Community Action (Berkeley: University of California Press, 1990); Barbara L. Allen, Uneasy Alchemy: Citizens and Experts in Louisiana’s Chemical Corridor Disputes (Cambridge, MA: MIT Press, 2003). 45. Sylvia Noble Tesh, Uncertain Hazards (Ithaca, NY: Cornell University Press, 2000); Jason Corburn, Street Science: Community Knowledge and Environmental Health Justice (Cambridge, MA: MIT Press, 2005). 46. James C. Whorton, Before Silent Spring: Pesticides and Public Health in Pre-DDT America (Princeton, NJ: Princeton University Press, 1975); Thomas Dunlap, DDT: Scientists, Citizens, and Public Policy (Princeton, NJ: Princeton University Press, 1983); Scott Frickel, Chemical Consequences: Environmental Mutagens, Scientist Activism, and the Rise of Genetic Toxicology (New Brunswick, NJ: Rutgers University Press, 2004); Pete Daniel, Toxic Drift: Pesticides and Health in the Post-World War II South (Baton Rouge: Louisiana State University Press, 2007); Linda Nash, Inescapable Ecologies: A History of Environment, Disease, and Knowledge, (Berkeley: University of California Press, 2007). 47. Rachel Carson, Silent Spring (New York: Houghton, 1962). 48. Randall M. Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007); Margaret Humphreys, Malaria: Poverty, Race, and Public Health in the United States (Baltimore: Johns Hopkins University Press, 2001). 49. James T. Patterson, The Dread Disease: Cancer and Modern American Culture (Cambridge, MA: Harvard University Press, 1987); Robert N. Proctor, Cancer Wars: How Politics Shapes What We Know and Don’t Know About Cancer (New York: Basic Books, 1996). 50. Mark Jackson, Allergy: The History of a Modern Malady (London: Reaktion Books, 2007); Gregg Mitman, Breathing Space: How Allergies Shape Our Lives and Landscape (New Haven: Yale University Press, 2007); Carla Keirns, ‘Short of Breath: A Social and Intellectual History of Asthma in the United States’, PhD, University of Pennsylvania, 2004. 51. C. E. Rosenberg, ‘Pathologies of Progress: The Idea of Civilization as Risk’, Bulletin of the History of Medicine, 72 (4) (1998), 714–30. 52. Proctor, Cancer Wars. 53. Mitman, Breathing Space; Nash, Inescapable Ecologies.

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Select Bibliography Bartrip, Peter W. J., The Way from Dusty Death: Turner and Newall and the Regulation of Occupational Health in the British Asbestos Industry, 1890s–1970 (London/New York: Athlone Press, 2001). Hurley, Andrew, Environmental Inequalities: Class, Race, and Industrial Pollution in Gary, Indiana, 1945–1980 (Chapel Hill: University of North Carolina Press, 1995). Jackson, Mark, Allergy: The History of a Modern Malady (London: Reaktion Books, 2007). McCulloch, Jock, and Geoffrey Tweedale, Defending the Indefensible: The Global Asbestos Industry and Its Fight for Survival (New York: Oxford University Press, 2008). McIvor, Arthur, and Ronald Johnston, Miners’ Lung: A History of Dust Disease in British Coal Mining (Aldershot: Ashgate, 2007). Mitman, Gregg, Breathing Space: How Allergies Shape Our Lives and Landscapes (New Haven, CT: Yale University Press, 2007). —— , Michelle Murphy, and Christopher Sellers (eds), Landscapes of Exposure: Knowledge and Illness in Modern Environments, Osiris, special issue, 19 (2004). Murphy, Michelle, Sick Building Syndrome and the Problem of Uncertainty: Environmental Politics, Technoscience, and Women Workers (Durham, NC: Duke University Press, 2006). Nash, Linda, Inescapable Ecologies: A History of Environment, Disease, and Knowledge (Berkeley: University of California Press, 2007). Rosner, David, and Gerald Markowitz, Deceit and Denial: The Deadly Politics of Industrial Pollution (Berkeley: University of California Press, 2002). Santiago, Myrna I., The Ecology of Oil: Environment, Labor, and the Mexican Revolution, 1900–1938 (Cambridge/New York: Cambridge University Press, 2006). Sellers, Christopher, Hazards of the Job: From Industrial Disease to Environmental Health Science (Chapel Hill: University of North Carolina Press, 1997). Valencius, Conevery Bolton, The Health of the Country: How American Settlers Understood Themselves and Their Land (New York: Basic Books, 2002). Warren, Christian, Brush with Death: A Social History of Lead Poisoning (Baltimore: Johns Hopkins University Press, 2000).

chapter 26

history of science a n d m edici n e s taffan m üller-wille

History is an instrument of life, and medical history is an instrument of medical life. Henry E. Sigerist, 1936

Despite the obvious connections between their respective fields of inquiry, historians of science and historians of medicine have had far less of a dialogue over historiographical issues than one might expect. This is in sharp contrast to the history of technology, which at least since Boris Hessen’s famous address to the Second International Congress of the History of Science and Technology in 1931 has regularly provoked debates about whether scientific knowledge is determined ‘externally’ by concerns with solutions to technological, social, and political challenges, or whether it results from an agenda defined ‘internally’ by scientists themselves.1 As Mark Jackson’s introduction to this volume demonstrates, historiographical debates among historians of medicine turn around a subtly, but revealingly different problem. What they focus on is not simply the question whether and how knowledge is socially and culturally constituted, but rather whether historical research can and should extract ‘lessons from the past’ for the health problems that we face today. In other words, the lack of communication between historians of science and historians of medicine seems to stem from the fact that the former tend to be interested in questions of epistemology, whereas the latter care more about questions that are ethical and political in nature. ‘Truth’, whether writ large or understood in terms of its distribution as local, culturally constituted knowledge, is usually the object of the history of science, while ‘health’, its changing distribution over populations, as well as the practices to promote and achieve it, tend to remain focal to the history of medicine. To some degree, this difference in orientation and perspective is only natural, given the traditional understanding of medicine as an art, rather than science. This understanding also underwrote the last open and widely noticed attack on the history of

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medicine by a historian of science. In 1935, George Sarton (1884–1956), founder of the flagship journal of the history of science, Isis, complained that the history of medicine received far too much attention for what it inadvertently revealed about subjects properly belonging to the history of science. ‘As the medical art applies to its own purposes every physical, chemical or biological discovery which is at all applicable,’ Sarton wrote, ‘the historian of medicine must necessarily mention these discoveries.’ These applications, however, were not much more than ‘the few medical twigs’ resulting from the growth of science proper.2 Interestingly, Henry E. Sigerist (1891–1957), an equally towering figure in the disciplinary foundation of twentieth-century history of medicine, did not base his reply on a reversal of Sarton’s image, with the results of so-called ‘pure science’ forming marginal outgrowths on a tree of knowledge firmly rooted in medicine. Instead he chose to base his reply on a wholesale rejection of Sarton’s imagery. ‘Medicine is not a branch of science’, Sigerist claimed, ‘and will never be.’ The physician’s goal is to cure disease—‘to keep his fellow-men socially adjusted or to readjust them if necessary’, as Sigerist chose to put it—and the history of medicine therefore had to deal with ‘the history of the relationships between physician and patient, between the medical profession (including administrators, public health officers, scientists, nurses, priests, quacks etc.) and society.’ This included attention to the application of scientific methods, but to other social, economic, political, and religious factors as well.3 Sigerist’s move to divorce the agenda of the history of medicine clearly and cleanly from that of the history of science has had a lasting effect in the English-speaking world, even on those who in the 1970s assembled under the banner of a ‘new’ social history of medicine to go beyond Whiggish accounts celebrating the successes of ‘scientific medicine’. The effect was twofold. First of all, science came to be placed among the external factors that shape medical thought and practice, rather than being considered a genuine product of medical history. This also holds for those historians of medicine who, like John Harley Warner, have more recently promoted a perspective of ‘science in medicine’. Drawing on the more fragmented and contextualized picture that historians of science have begun to paint of the development of science since their ‘cultural’ and ‘practical’ turn in the early 1980s, Warner argues that it is time to give up the neat distinction between medicine as art and medicine as science that has served so well to separate the two fields. Yet, his own account of ‘science in medicine’ largely portrays science as an external, ideological resource that providers of medical services, and in certain circumstances even their clients, exploit in attempts to secure their authority and social status.4 The second effect was that with ‘health’, rather than ‘truth’, as their focal object of inquiry, medical historians remained largely immune to relativist, let alone radically constructionist, outlooks. Many studies continue to take the massive demographic changes in mortality rates and life expectancy in the past 250 years as their starting point, or focus on changing perceptions of the human body, health, and illness. With these changes as a starting point, rather than changes in world view, some degree of realism seems unavoidable; or, if constructivist readings of health and its history are proposed, construction is taken literally in a way that dissociates itself from the anti-realism prevalent among some scholars of science. Health and illness, let alone life and death, matter

history of science and medicine

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too much, both for historians of medicine and for their audiences, to be reducible to discourse alone.5 In this chapter, I want to explore what both historians of medicine and historians of science could gain from a stronger entanglement of their respective research agendas. In order to do this, I will first give a cursory outline of the history of the relationship between science and medicine since the scientific revolution in the seventeenth century. As will become evident, medicine can very well be seen as a domain that was highly productive of scientific knowledge, yet in ways that do not fit very well with the historiographic framework that dominated the history of science until recently, namely Thomas S. Kuhn’s theory of normal, paradigmatic science punctuated by scientific revolutions. The two following sections will then discuss two alternative historiographical approaches, those of Ludvik Fleck (1896–1961) and Georges Canguilhem (1904–95). Both Fleck and Canguilhem, I will argue, offer ways of thinking about the growth of knowledge that fit well with the cumulative and translational patterns that characterize the development of the medical sciences, and also provide an understanding of concepts such as ‘health’ and ‘life’ that goes beyond mere discourse analysis.

Medicine and the scientific revolution Medicine and the sciences have enjoyed an intimate relationship since the dawn of natural philosophy in Greek antiquity. Many of the key concepts of Aristotelian natural philosophy resonate with themes familiar from the Hippocratic corpus. This is true for Aristotle’s theory of four elements, his analysis of causality into four causes (material, formal, effective, and teleological), and his views about the relationship between the macrocosm and the microcosm, the former generating and shaping the latter through the seasonal cycle. An Aristotelian metaphor that brings the close relationship between medicine and natural philosophy to the fore is that of nature, or physis, as a physician healing himself (Physics, 192b25f.). Sigerist would therefore not have been entirely misguided had he claimed against Sarton that the more abstract natural sciences were actually rooted in medicine, not the other way round.6 It is therefore a mistake to rashly associate the abstract nature of scholastic reasoning with its Aristotelian heritage. The Salernitan reform around 1200, re-establishing the Galenic tradition in Europe, the eventual association of medical teaching with universities, and the late medieval translation activities in Islamic Spain, Northern Italy, and Bycance, which gave Europe knowledge of Aristotle’s biological treatises, most of Galen’s texts, and above all Avicenna’s Canon, if anything collectively renewed attention to particulars, to the structures and functions of the human body, the incidence of disease, and the varieties of remedies. Late-sixteenth-century learned medicine at universities like Padua or Bologna, fully immersed in Aristotelian naturalism as it was, thus fed important impulses into the scientific revolution. William Harvey (1578–1657) and his discovery of the circulation of blood (1628) provides one of the most prominent examples.7

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When the centres of medical learning moved northwards in the seventeenth century, to Leiden in particular, and ushered in the scientific revolution, it was therefore not so much the contents and styles of reasoning that changed, but rather the very fabric of the hierarchy of knowledge. Traditionally, learned medicine had envisaged a clear-cut hierarchy between theoretical knowledge based on explicit, deductive reasoning from universally accepted statements, on the one hand, and practical knowledge based on experience and manual skills, on the other. This relationship was upset during the scientific revolution. In their competition for clients among wealthy, urban elites, university physicians began to rely on the practices of surgeons (dissection), apothecaries (pharmacology), and general practice (therapeutics and collections of case studies), whereas the latter groups sought recognition through emulation of forms of training, association, and graduation characteristic of universities. No clear distinction between science and art existed anymore in a multiplicity of institutions and organizations competing for authority over medicine.8 The resultant eclecticism became visible in iatromechanism (mechanics had always been considered an art, rather than a science) and iatrochemistry, with Herman Boerhaave (1668–1738) as one of the most prominent protagonists. Conflicts continued between learned physicians, on the one hand, and surgeons or apothecaries, on the other, in the eighteenth century, resulting in a growing role for state institutions like health boards as mediators.9 The French Revolution in particular created new responsibilities of medical professions for hospitals, public health, and hygiene that soon set standards for other European nation-states. Concentration of patients in hospitals as well as record-keeping practices for administrative purposes created institutional conditions for new biomedical disciplines like pathological anatomy or medical topography. Another important factor feeding into a profusion of new medical specialities was the creation of the research university, especially in Prussia. Disciplines like organic chemistry, cytology, experimental physiology, or bacteriology emerged in this context, often in close connection with medical faculties.10 What makes these developments particularly interesting for the historian of science is the fact that they did not parallel, let alone succeed, the ‘birth’ of biology around 1800, but very often created the conditions that allowed for the formation of central biological concepts. A well-studied example is that of heredity, a concept that was first formulated by physicians, French alienists in particular, and only then became of central concern for biologists such as Charles Darwin (1809–82).11 Similar arguments could be made for such central biological concepts as population, cell, or enzyme. At the end of the nineteenth century, forms of health administration and medico-industrial application had developed that would shape twentieth-century laboratory science to a considerable degree and eventually lead to the confluence of medicine and the life sciences after the Second World War.12 Financially powerful funding organizations like the Rockefeller Foundation or the Wellcome Trust after all defined their objectives often in terms of medical or even social engineering.13 Still, most grand narratives of the triumph of ‘scientific medicine’ see medicine impacted by science rather than the other way round. One major reason for this may

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well be that the history of science itself started out by looking at the physical sciences, mechanics, optics, and thermodynamics in particular. This is still true for Thomas S. Kuhn’s account of the development of the sciences in The Structure of Scientific Revolutions (1962), which was heavily influenced by Alexandre Koyré (1892–1964). Koyré had argued that Galileo’s crucial step in consolidating mechanics as a science was to apply mathematics to terrestrial phenomena, rather than taking clues from the experimental practices of engineers and craftsmen.14 Kuhn followed Koyré in this by restricting himself to what he termed ‘mature’ sciences, that is, sciences in possession of a paradigm, or exemplary achievement, that defines norms, standards, and theoretical generalizations for its practitioners. From adherence to a paradigm, scientific communities derive a sense of unity and purpose that in effect seals them off from external agendas and engages them in activities of puzzle-solving constituting largely progressive and cumulative ‘normal’ science.15 Some problems, however, resist resolution and constitute ‘anomalies’, which lead to a feeling of crisis once they accumulate. As paradigms behave as wholes, the way out of such crises can only lead through a process of conversion to a new paradigm. The resulting overall picture of the development of science has surprising similarities with Sarton’s tree, despite its emphasis on discontinuity and non-directedness. Kuhn would later compare the pattern of scientific revolutions to a branching tree of biological species, a simile underscoring his view of scientific communities as esoteric, relatively isolated elites.16 Kuhn’s account of the history of science has no doubt provoked fascinating case studies, not the least by himself, and is largely responsible for making science accessible to the methods of cultural and social history.17 Yet it lends itself with difficulty to being applied to the history of medicine. The reasons for this are twofold. On the one hand, much of the interaction between science and medicine follows the patterns of ‘immature’, ‘Baconian’, or ‘preparadigmatic’ sciences, as Kuhn called them, which endorse a pluralism of beliefs and methodologies and engage in fact-gathering rather than puzzle-solving.18 The lack of a clear paradigm should not be confused with historical insignificance, however. Harold C. Cook has recently gone as far as claiming that the Scientific Revolution as a whole was driven by Baconian ‘natural and experimental history’, more often than not with medical concerns at its core.19 What comes first in most medical sciences is not theoretical closure, but rather the opening up of a domain of enquiry for practices of fact-gathering and experimentation, something particularly difficult when it comes to human bodies and populations.20 Even the few candidates for a ‘paradigm’ in medicine, like the achievements of Louis Pasteur (1822–95) and Robert Koch (1843–1910) in bacteriology, were soon swamped in anomalies like ‘healthy carriers’, which in turn needed intense data collection and experimental activities for their resolution, resulting in something like a state of ‘permanent crisis’.21 As philosopher of biology Marjorie Grene pointed out in a polemical paper long ago, even a superficial look at a randomly chosen medical textbook—her choice fell on John F. Murray’s The Normal Lung (1876)—demonstrates that ‘scientific knowledge is overwhelmingly cumulative’.22

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The second reason why Kuhn’s theory of scientific change was rarely taken up by medical historians may lie in the fact that medical scientists can hardly do without borrowing from and communicating with other social groups, not least clinicians, but also specialists from neighbouring disciplines. Translation between communities in the history of medicine is omnipresent and fraught with difficulty and conflict.23 But it is also clearly unavoidable, as demonstrated perhaps most prominently, and provocatively, by Bruno Latour’s analysis of how Pasteur spread his gospel in France.24 In medicine, moreover, translation will necessarily involve normative and political issues, as health is an intrinsically value-laden subject of enormous political relevance. In order to account for these peculiarities, which remove medicine far from the ideal of Kuhn’s ‘mature’ sciences, it is necessary to look for other historiographical resources. We find them in two twentieth-century thinkers who devoted much of their historical research to medical topics, yet curiously have so far largely been received by the history of science only.

Translation and progress It is well known that the book Genesis and Development of a Scientific Fact (Entwicklung und Entstehung einer wissenschaftlichen Tatsache, 1935) by the Polish bacteriologist and immunologist Ludwik Fleck belongs to the few sources of inspiration that Kuhn could draw upon.25 Not surprisingly, therefore, there have been a number of publications from philosophers and sociologists of science, exploring the similarities and differences that exist between Fleck’s and Kuhn’s accounts of scientific development. Differences notwithstanding, all authors seem to agree that both Fleck and Kuhn proposed ‘that “scientific facts” are produced locally by a relatively small group of professionals—“thought collectives”—that share a “thought style”—a given body of knowledge and practices.’26 Indeed, there exist clear analogies between what Fleck called ‘thought collectives’ and ‘thought styles’ on the one hand, and Kuhn’s ‘scientific communities’ and ‘paradigms’ on the other. Both defined these terms by their mutually constitutive relation, both pointed to the empirically verifiable existence of institutions of tradition and education in order to avoid circular reasoning, and both portrayed individual scientists as thinking and acting under the constraints of collective ‘thought styles’ or ‘paradigms’, which gave their work direction and purpose, but also resulted in communication problems.27 Yet it is quite clear that for Fleck, the processes that lead to the verification and reification of factual or ‘authorless’ knowledge, as he put it, do not consist in social or conceptual closure, but rather in the translation, migration, and circulation of ‘thoughts’ and ‘ideas’ among different collectives; or to put it differently he was concerned with the ‘genesis and development of a fact’ between, not within, social groups. This emerges perhaps more clearly from a programmatic paper that he published in 1936 under the title of ‘The Problem of Cognition’, than from his 1935 book, which entangles a long and circuitous case study (the history of syphilis) with epistemological and historiographical

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reflections. In ‘The Problem of Cognition’, Fleck claimed that any epistemology that wanted to avoid the ‘fundamental error’ of hypostasizing a ‘symbolic epistemological subject’ had to acknowledge ‘three basic phenomena’: (1) the ‘collective mental differentiation of men’; (2) ‘the fact that the circulation of thought is always related, in principle, to its transformation’; and (3) the ‘existence of a specific historical development of thinking, which cannot be reduced to the logical development of thought-contents nor to simple increase of detailed information’.28 It is worthwhile dwelling on each of these three ‘basic phenomena’ one by one to bring out the differences that lie between Fleck’s and Kuhn’s account of scientific growth. The first relies on a mundane observation: most of what people know, they do not learn from first-hand experience, but from tradition and training, and what they learn in these ways in turn differs from individual to individual depending on social status and the division of labour. Fleck’s notion of a thought collective is thus much more loosely defined than Kuhn’s scientific communities. First, it also includes such social entities as political parties and religious groups. And secondly, any one individual will as a rule belong to more than one thought collective. This is also why for Fleck, translation problems are not absolute, but come by degree. Some thought styles approach each other, others are more distant from another, and in some cases this distance may lead to a breakdown in communication. Thought collectives tend to have an internal structure, with an esoteric core of experts surrounded by more and more inclusive exoteric circles of peers and amateurs. It is at this point that the second of Fleck’s three ‘basic phenomona’ comes into play and it is here that we encounter the strongest difference between Fleck’s model of scientific growth and the one Kuhn would later develop. According to Kuhn, scientific change consists of the successive emergence or differentiation of paradigms, which, in analogy to biological species, are effectively isolated from each other. Fleck, on the other hand, wanted to draw attention to the ‘circulation of thought’ as the basic condition of scientific change. Again, Fleck relied on some rather basic features of communication to argue for this view. Each communication, he explained, is ‘directional’, that is, it is addressed to someone, and thus ‘bears the sign of the producing unit and the address of destination’. In other words, in communicating one does not only take into account the thought style of the thought collective to which one belongs, but also that of the thought collective addressed, resulting in the transformation of the communicated thought. Fleck thus understood translation as a social interaction. In accordance with this, Fleck considered translation as a process proceeding in two fundamental directions: ‘propaganda’ proceeds outwards, so to speak, by progressively adapting an esoteric thought to the thought style of ever-growing exoteric circles; whereas ‘legitimization’ proceeds the other way, by adopting thoughts from exoteric circles for the purposes of ever more circumscribed esoteric collectives. At each point along its paths of propaganda and legitimization, the thought ‘interferes’ with prevalent thought styles and alters its content. Such movements may be unintended and their net result may leave the thought, as Fleck expressed it, ‘authorless’ in as much as its content is ‘not produced by [an] individual but originates a motu sociali’. There is, finally, a third

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way in which thoughts are communicated, information, by which statements are ‘exchanged among specialists who are equivalent in a given field’. In this case, communication approaches the ‘exchange of conventional signals’. This comes closest to what Kuhn called ‘normal science’ proceeding within a paradigm. Interestingly, Fleck regarded it as playing ‘the least role in the real, socially important exchange of ideas’. According to Fleck’s model, scientific progress occurs where thoughts interfere with each other as a result of popularization and legitimization. This is the basis from which Fleck develops his third ‘fundamental phenomenon of epistemology’, namely ‘the existence of a specific historical development of thinking, which cannot be reduced to the logical development of thought-contents’. The paths along which thoughts travel in their circulation are determined historically and the conjunctions they enter do not relate to their original sources as a conclusion or inference does to its premises. There is, and here Fleck drew on the example he developed in great detail in his Genesis and Development of a Scientific Fact, no logical connection between the Wassermann reaction, a complex serological procedure, and older, popular notions of syphilis as an ‘alteration of blood’. And yet there is a ‘strict genetical connection’ that brought together ‘the notion of a blood test and the notion of syphilis’ in attempts to specify both. To cut a long and complicated story brutally short, ‘Wassermann and his co-workers shared a fate with Columbus . . . What they achieved was not even their goal. They wanted evidence for an antigen or an amboceptor. Instead they fulfilled the ancient wish of the collective: the demonstration of syphilitic blood.’29 Again, there is a marked difference with respect to the picture that Kuhn would later draw of scientific change: turning points in the history of science do not consist of those rare moments in which one theory replaces the other; they rather consist in those more ubiquitous moments where concepts, instruments, and procedures enter novel, unexpected, and often unintended connections. Indeed, the notion of scientific revolutions is conspicuously absent from Fleck’s theory of science and he seems to have endorsed a cumulative notion of scientific growth. The final section of Fleck’s paper on the problem of epistemology addressed this topic by asking how ‘the idea of truth as representation of reality independent of the subject of cognition originates’. It begins with a discussion of the ‘democratic’ constitution of modern science, in which ‘the criterion of truth is found—at least in principle—in the general public’. Fleck diagnosed a ‘certain discrepancy’ between this ‘main postulate of [modern] science’ and its organization into highly esoteric groups to which access is gained only through long years of specialized training. This gap is bridged by what Fleck referred to as the process of ‘factogenesis’, which turns scientific judgements, tentatively suggested by the vanguard of specialist research, into ‘perceivable forms’ or ‘things’ that percolate to the exoteric circles of the uninitiated general public—a general public that nota bene includes scientists of other disciplinary specialities. Two means of science in particular were highlighted by Fleck as ‘giving the character of things to its creations’. Firstly, technical terms, whose power resides ‘in detaching their significance from the subject of cognition’ and which, in their most powerful form, consist in symbolic algorithms, like those of mathematics and logic; secondly, scientific devices, such as measuring instruments and appliances like the

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telescope, which are ‘the realization of some result of a definite thought-style’ and direct ‘our thinking automatically on the tracks of that style’.

Concepts in history Fleck’s theory of knowledge continued a long Polish tradition of philosophy of medicine that reacted to the widespread perception that scientific medicine, just as science in general, had become alienated from the concerns and perceptions of everyday people, and had thus entered a state of ‘crisis’.30 Fleck was particularly critical of the attempts of the Vienna Circle to bridge the gap between vernacular and scientific thinking by reducing the latter to two allegedly universal sources of knowledge, logic and sensory data. ‘Thought-styles’ remained irreducibly diverse and one of the chief characteristics of modern science was its inaccessibility to others but its own practitioners. ‘The more scientific knowledge becomes generalized, the more it becomes exclusive and difficult to attain,’ Fleck once maintained and went on to explain: It was once thought that science would make that mysterious and intricate complex, called Nature, somehow simple and easier to grasp for the mind. Instead, science has become a structure, which as a whole is not at all simpler than Nature, but which is much harder to attain. It is easier to find one’s way in the woods than in botany. It is also easier to cure a patient than to know what he is really suffering from.31

In this quote from a 1939 paper on ‘Science and Its Environment’, which still awaits translation into English, Fleck expressed a conviction that forms the core of continental history and philosophy of science, namely that science does not proceed from common sense, but rather goes against and eventually overcomes it. In France, it was Gaston Bachelard (1882–1962), who most eloquently defended this point of view in The Formation of the Scientific Mind (La formation de l’esprit scientifique, 1938). Relying on examples from eighteenth-century science, Bachelard demonstrated that analytic and quantitative perspectives had to prevail against ‘epistemological obstacles’—perceptions, associations, and attitudes deeply rooted in everyday life, like the tendency to form an opinion on the basis of first impressions.32 He expanded his analysis, which shows distinct traces of his earlier engagement as a primary school teacher, to the modern laboratory sciences in a series of publications after the war and his work had a profound influence on the French School of ‘historical epistemology’.33 This school has indirectly impacted the English-speaking world through the work of Michel Foucault (1926–84), but I will approach it through the work of Foucault’s teacher and mentor, Georges Canguilhem. As Jean-François Braunstein has pointed out, there exist a number of parallels between Fleck’s and Canguilhem’s historiographical approaches. Both conceived of knowledge as an essentially historical and social phenomenon and were critical of the project of the Vienna Circle and the analytical philosophy of science that grew out of it.

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Both were sceptical about scientific revolutions and conceptual ‘ruptures’ (Bachelard’s term) and preferred thinking in terms of the continuous formation and subsequent deformation (or ‘rectification’, as Canguilhem put it) of concepts. And both, finally, emphasized that certain ‘pre-ideas’ (Fleck) or ‘ancient images’ (Canguilhem), such as the idea of disease as a disturbance of balance, provided an element of continuity that linked the specialized pursuits of scientists with pre- and extra-scientific concerns.34 Yet despite all these commonalities, Canguilhem presents us with a strikingly different œuvre, which at first sight seems to resemble an old-fashioned history of ideas. His two books and numerous collections of articles contain little in terms of a social and cultural history of science and medicine. Instead, they focus entirely on the longue durée history of certain fundamental concepts such as regulation, reflex, or vital force. In order to see the significance of Canguilhem’s work, one must attend to the kind of concepts he chose to work on and to his curious understanding of their historicity. Regarding the first point, his choice usually fell on concepts that in one way or other related to Canguilhem’s conviction that normativity—in the sense of the capacity to adopt, but also to deviate from, norms—is the defining property of the object of the biomedical sciences, life itself. His first book, The Normal and the Pathological (Le normal et le pathologique, 1943; second edition 1966) espoused this conviction perhaps most directly, by arguing that the various attempts made by nineteenth- and twentiethcentury life scientists to reduce the state of health to some ‘normal’ condition of the body, while scientifically productive, never successfully escaped the conclusion that health, in the last analysis, is characterized by the ‘possibility of . . . instituting new norms in new situations’.35 Health and disease, to put this point bluntly, are relative to given situations— overwhelmingly historical and social in their nature, in the case of humans—and thus subject to processes of disturbance, recovery, and adaptation. This thought forms the central theme of Canguilhem’s numerous studies of other biomedical concepts as well. His book-length study of the formation of the concept of reflex movement, for example, was motivated by his conviction that mechanist explanations of this phenomenon ultimately failed to capture the sense in which ‘reflex movement, even in its simplest, most analytical form, was a form of behaviour, the reaction of an organic whole to a change in its relation to the environment.’36 Similar themes are prominent in his essays on the concept of regulation, the cell, the monstrous, or the machine organism.37 Canguilhem’s vitalism should not be seen as an attempt to reach for an ‘objective’ definition of life, against which historical contributions to the biomedical sciences were to be evaluated. This would have amounted to a category mistake by conflating the object of the history of science with the object of the science it looks at. The object of the history of science, Canguilhem explained, was rather the ‘historicity of scientific discourse, insofar as it expresses a procedure that is normalized from within, but is punctuated by accidents, impeded or thwarted by obstructions, and interrupted by crises, that is moments of judgement and truth’.38 With unmistakable echoes from Bachelard’s philosophy of science, Canguilhem here defines science not just as discourse, but in terms of an underlying struggle to overcome error and reach for truth. Science and its products—concepts, standards, and technologies—are themselves powerful expressions of the normativity

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that is characteristic of life. As Foucault put it in his introduction to the English translation of The Normal and the Pathological, one of his last, and perhaps most lucid, texts: ‘Forming concepts is one way of living, not of killing life.’39 The meaning of a concept does thus not exhaust itself in its discursive relationship to other words and texts only, neither for Canguilhem, nor for Foucault, as the latter’s influential ‘archaeological’ works on the emergence of the clinical and human sciences around 1800 might suggest.40 Concepts also articulate dynamic power relationships of authority and resistance by advancing certain evaluations in order to contest or overcome others, a perspective that Foucault first developed programmatically in his essay ‘Nietzsche, Genealogy, and History’ (1971), and then explored for concepts such as sexuality and race.41 In The Normal and the Pathological, Canguilhem endorsed the same point of view when he claimed that, prior to all attempts at objective definition, the concept of health must be understood as ‘a way of tackling existence as one feels that one is not only possessor or bearer but also, if necessary, creator of value, establisher of vital norms’.42 Echoing Sigerist, on whose work he relied to quite some extent, Canguilhem therefore claimed that concepts of health and disease could not be dissociated from the irreducibly social relations established by the practice of medicine.43 Gaining knowledge, whether scientific, medical, or vernacular, is not simply a way of representing, but of intervening in, the world.44

Conclusion Historical studies of science have moved well beyond Kuhn in the past three decades. Steven Shapin and Simon Schaffer have demonstrated in a paradigmatic study how what Kuhn termed ‘mature’ science was itself a product of debates about the nature of knowledge in the early days of the Royal Society.45 Peter Galison has emphasized the importance of the emergence of trading zones and pidgin languages, between scientists and engineers in particular, for the formation of twentieth-century particle physics.46 And historians and sociologists have drawn attention to ‘experimental systems’ and ‘biomedical platforms’—that is, loose assemblages of objects, instruments, people, and institutions—as the dynamic entities that have shaped research objects and agendas of the molecular life sciences in the twentieth century.47 Recent history of science, that is, offers a rich arsenal of concepts and case studies that allow us to address the production of scientific knowledge as something proper, rather than extraneous, to the history of medicine, without falling back into the grand narrative of the ‘triumph of scientific medicine’. Accordingly, John Pickstone has made the interesting suggestion to drop the fixation with disciplinary divides entirely, and to treat science, medicine, and technology as a continuum structured by different ‘ways of knowing’—natural history, analysis, and experimentalism.48 Historical case studies along these lines could certainly help to overcome widespread contemporary perceptions that it is only very recently that ‘basic’ and ‘applied’ science have begun to interact to a degree that they have become effectively

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undistinguishable. Yet it is unlikely—nor was it intended by Pickstone—that the history of medicine will cease to have health as its vanishing point and replace it with some general concept of knowledge. Health, as pointed out at the beginning of this essay, just matters too much for this to happen. A mutual rapprochement of the history of medicine and the history of science could only benefit both disciplines, however, by restoring a sense of the ways in which knowledge has shaped human life.

Notes 1. See the special issue on ‘Technoscientific Productivity’ of Perspectives on Science, 13 (2 and 3) (2005), edited by Ursula Klein. 2. George Sarton, ‘The History of Science versus the History of Medicine’, Isis, 23 (2) (1935), 313–20, at 316–17. 3. Henry E. Sigerist, ‘The History of Medicine and the History of Science’, Bulletin of the Institute of the History of Medicine, 4 (1) (1936), 1–13, at 5. On Sigerist’s historiographical ideas, see Elizabeth Fee, ‘From the Social Production of Disease to Medical Management and Scientific Socialism’, Milbank Quarterly, 67 (Suppl. 1) (Framing Disease: The Creation and Negotiation of Explanatory Schemes, 1989), 127–50; and Elizabeth Fee and Theodore M. Brown, ‘Using Medical History to Shape a Profession: The Ideals of William Osler and Henry E. Sigerist’, in Frank Huisman and John Harley Warner (eds), Locating Medical History: The Stories and Their Meanings (Baltimore: Johns Hopkins University Press, 2004), 139–64. 4. John Harley Warner, ‘The History of Science and the Sciences of Medicine’, Osiris, 10 (1995), 164–93; for a similar view see S. E. D. Shortt, ‘Physicians, Science and Status: Issues in the Professionalization of Anglo-American Medicine in the Nineteenth Century’, Medical History, 27 (1983), 51–68. 5. Charles E. Rosenberg, ‘Disease in History: Frames and Framers’, Milbank Quarterly, 67, Suppl. 1 (1989), 1–15; Ludmilla Jordanova, ‘The Social Construction of Medical Knowledge’, in Huisman and Warner (eds), Locating Medical History, 338–63. 6. Gert E. Brieger, ‘The History of Science and the History of Medicine’, Isis, 72 (4) (1981), 536–40. 7. Charles B. Schmitt, ‘Aristotle among the Physicians’, in Andrew Wear, Roger Kenneth French, and Iain M. Lonie (eds), The Medical Renaissance of the Sixteenth Century (Cambridge: Cambridge University Press), 1–15. 8. Harold J. Cook, ‘Medicine’, in Katharine Park and Lorraine Daston (eds), Early Modern Science (Cambridge: Cambridge University Press, 2006), 407–34. 9. William F. Bynum, ‘Health, Disease and Medical Care’, in G. S. Rousseau and Roy Porter (eds), The Ferment of Knowledge: Studies in the Historiography of Eighteenth-Century Science (Cambridge: Cambridge University Press, 1980), 211–53. 10. John E. Lesch, Science and Medicine in France: The Emergence of Experimental Physiology 1790–1855 (Cambridge, MA: Harvard University Press, 1984); William F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994). 11. Robert C. Olby, ‘Constitutional and Hereditary Disorders’, in W. F. Bynum and Roy Porter (eds), Companion Encyclopedia of the History of Medicine (London: Routledge, 1993),

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12.

13. 14. 15.

16.

17.

18. 19. 20. 21.

22.

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412–37; Carlos López Beltrán, ‘In the Cradle of Heredity: French Physicians and l’hérédité naturelle in the Early Nineteenth Century’, Journal of the History of Biology, 37 (1) (2004), 39–72; Staffan Müller-Wille and Hans-Jörg Rheinberger (eds), Heredity Produced: At the Crossroads of Biology, Politics and Culture, 1500–1870 (Cambridge, MA: MIT Press, 2007). Steve Sturdy, ‘The Political Economy of Scientific Medicine: Science, Education and the Transformation of Medical Practice in Sheffield, 1890–1922’, Medical History, 36 (1992), 125–59; Ilana Löwy, Olga Amsterdamska, John Pickstone, and Patrice Pinell (eds), Medicine and Change: Historical and Sociological Studies of Medical Innovation (Paris: Les Éditions INSERM, 1993); Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000); Jean-Paul Gaudillière, L’Invention de la biomédecine: La France, l’Amérique et la production des savoirs du vivant après 1945 (Paris: La Découverte 2002); Viviane Quirke and Jean-Paul Gaudillière, ‘The Era of Biomedicine: Science, Medicine and Public Health in Britain and France after the Second World War’, Medical History, 52 (4) (2008), 441–52. Lily E. Kay, The Molecular Vision of Life: Caltech, the Rockefeller Foundation, and the Rise of the New Biology (Oxford: Oxford University Press, 1993). Alexandre Koyré, ‘Galileo and Plato’, Journal of the History of Ideas, 4 (1943), 400–28. Thomas S. Kuhn, ‘Second Thoughts on Paradigms’, in idem, The Essential Tension: Selected Studies in Scientific Tradition and Change (Chicago: University of Chicago Press, 1977), 293–319. Thomas S. Kuhn, ‘The Road since Structure’, in The Road Since Structure: Philosophical Essays 1970–1993, with an Autobiographical Interview (Chicago: University of Chicago Press, [1991] 2000), 90–104. It is important to note that Kuhn—unlike some of his fellow philosophers of science at the time, especially David L. Hull in his Science as a Process: An Evolutionary Account of the Social and Conceptual Development of Science (Chicago: University of Chicago Press, 1988)—did not want to imply that the actual mechanisms of change in science were the same as in biological evolution; see Thomas A. C. Reydon and Paul Hoyningen-Huene, ‘Discussion: Kuhn’s Evolutionary Analogy in Structure of Scientific Revolutions and “The Road since Structure” ’, Philosophy of Science, 77 (3) (1993), 468–76. For interesting assessments of Kuhn see Barry Barnes, T. S. Kuhn and Social Science (New York: Columbia University Press, 1982); and Steven Fuller, Thomas Kuhn: A Philosophical History of Our Times (Chicago: University of Chicago Press, 2000). Fuller’s analysis is polemical, but makes the interesting point that Kuhn’s portrayal of science as a pursuit of isolated elites is related to issues raised by the Cold War. Thomas S. Kuhn, ‘The History of Science’, in The Essential Tension, 105–26. Harold J. Cook, Matters of Exchange: Commerce, Medicine, and Science in the Dutch Golden Age (New Haven, CT: Yale University Press, 2007). Ilana Löwy, ‘The Experimental Body’, in Cooter and Pickstone (eds), Medicine in the Twentieth Century, 435–49. Pauline M. H. Mazumdar, Species and Specificity: An Interpretation of the History of Immunology (Cambridge: Cambridge University Press, 1995); Ilana Löwy and Jean-Paul Gaudillière (eds), Heredity and Infection: The History of Disease Transmission (London: Routledge, 2001). Marjorie Grene, ‘Philosophy of Medicine: Prolegomena to a Philosophy of Science’, PSA 1976: Proceedings of the Biennial Meeting of the Philosophy of Science Association, 2 (1976), 77–93, at 86.

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23. Christopher Lawrence, ‘Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850–1914’, Journal of Contemporary History, 20 (4) (1985), 503–20. 24. Bruno Latour, The Pasteurization of France, trans. A. Sheridan and J. Law (Cambridge, MA: Harvard University Press, [1984] 1988). 25. Thomas S. Kuhn, ‘Foreword’, in Ludwik Fleck, Genesis and Development of a Scientific Fact, ed. Thaddeus T. Trenn and Robert K. Merton, trans. Fred Bradley and Thaddeus J. Trenn (Chicago: University of Chicago Press, 1979), vii–xi. 26. Ilana Löwy, ‘Introduction: Ludwik Fleck’s Epistemology of Medicine and Biomedical Sciences’, Studies in History and Philosophy of Biological and Biomedical Sciences, 35 (4) (2004), 437–45, at 438. 27. Stig Brorson and Hanne Andersen, ‘Stabilizing and Changing Phenomenal Worlds: Ludwik Fleck and Thomas Kuhn on Scientific Literature’, Journal for General Philosophy of Science, 32 (2001), 109–29. 28. Ludwik Fleck, ‘The Problem of Cognition’, in Cognition and Fact: Materials on Ludwik Fleck, ed. Robert S. Cohen and Thomas Schnelle (Dordrecht: Kluwer, [1936] 1986), 79–112. 29. Fleck, Genesis and Development of a Scientific Fact, 69–70. 30. Ludwik Fleck, ‘On the Crisis of Reality’, in Cognition and Fact [1929], 47–57. On Fleck’s philosophical context see Ilana Löwy, The Polish School of Philosophy of Medicine: From Tytus Chalubinsky (1820–1889) to Ludwik Fleck (1896–1961) (Dordrecht: Kluwer, 1990). 31. Quoted from Löwy, The Polish School of Philosophy of Medicine, 254. 32. Gaston Bachelard, The Formation of the Scientific Mind: A Contribution to a Psychoanalysis of Objective Knowledge, trans. Mary MacAllester Jones (Manchester: Clinamen Press, 2002). 33. Dominique Lecourt, Marxism and Epistemology: Bachelard, Canguilhem and Foucault, trans. Ben Brewster (London: New Left Books, 1975); Hans-Jörg Rheinberger, On Historicizing Epistemology (Stanford: Stanford University Press, 2010). 34. Jean-François Braunstein, ‘Deux philosophies de la médicine: Canguilhem et Fleck’, in Anne Fagot-Largeault and Hee-Jin Han (eds), Philosophie et médicine: en hommage à Canguilhem (Paris: J. Vrin, 2008), 63–80. 35. Georges Canguilhem, The Normal and the Pathological, trans. Carolyn R. Fawcett (New York: Zone Books, [1966] 1991), 196–97; Jean Gayon, ‘The Concept of Individuality in Canguilhem’s Philosophy of Biology’, Journal of the History of Biology, 31 (3) (1998), 305–25. 36. Georges Canguilhem, A Vital Rationalist: Selected Writings, ed. François Delaporte, trans. Arthur Goldhammer (New York: Zone Books, 1991), 201. 37. Georges Canguilhem, Ideology and Rationality in the History of the Life Sciences, trans. Arthur Goldhammer (Cambridge, MA: MIT Press, 1988); idem, Knowledge of Life, ed. Paola Marrati and Todd Meyers, trans. Stefanos Geroulanos and Daniela Ginsburg (New York: Fordham University Press, 2008). 38. Georges Canguilhem, ‘L’objet de l’histoire des sciences’, in Études d’histoire et de philosophie des sciences (Paris: Vrin, 1968), 9–23. Canguilhem, A Vital Rationalist, 25–31, provides a partial translation of this essay. I here follow the translation given in Rheinberger, On Historisizing Epistemology, 65. 39. Canguilhem, The Normal and the Pathological, 21. 40. Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (London: Tavistock, [1963] 1973); idem, The Order of Things: An Archeology of the Human Sciences (New York: Random House, [1966] 1970). 41. Michel Foucault, ‘Nietzsche, Genealogy, History’, in Paul Rabinow (ed.), The Foucault Reader (New York: Pantheon Books, [1971] 1984), 76–100; Michel Foucault, The History of

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42. 43. 44. 45. 46. 47.

48.

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Sexuality, Vol. 1, trans. Robert Hurley (New York: Random House, 1978); idem, Society Must Be Defended: Lectures at the College de France, 1975–1976, ed. Mauro Bertani and Alessandro Fontana, trans. David Macey (New York: Picador, 1997). Canguilhem, The Normal and the Pathological, 201. Ibid. 229. Ian Hacking, Representing and Intervening: Introductory Topics in the Philosophy of Science (Cambridge: Cambridge University Press, 1983). Steven Shapin and Simon Schaffer, Leviathan and the Air-Pump: Hobbes, Boyle, and the Experimental Life (Princeton, NJ: Princeton University Press, 1985). Peter Galison, Image and Logic: A Material Culture of Microphysics (Chicago: University of Chicago Press, 1997). Hans-Jörg Rheinberger, Toward a History of Epistemic Things: Synthesizing Proteins in the Test Tube (Stanford: Stanford University Press, 1997); Peter Keating and Alberto Cambrosio, ‘Biomedical Platforms’, Configurations, 8 (3) (2000), 337–88. John Pickstone, Ways of Knowing: A New History of Science, Technology and Medicine (Manchester: Manchester University Press, 2000); Ian Hacking, ‘ “Style” for Historians and Philosophers’, Studies in History and Philosophy of Science, 23 (1) (1992), 1–20.

Select Bibliography Bynum, William F., Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994). Canguilhem, Georges, The Normal and the Pathological, trans. Carolyn R. Fawcett (New York: Zone Books, [1966] 1991). —— Ideology and Rationality in the History of the Life Sciences, trans. Arthur Goldhammer (Cambridge, MA: MIT Press, 1988). —— Knowledge of Life, ed. Paola Marrati and Todd Meyers, trans. Stefanos Geroulanos and Daniela Ginsburg (New York: Fordham University Press, 2008). Cooter, Roger, and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000). Fleck, Ludvik, Genesis and Development of a Scientific Fact, ed. Thaddeus T. Trenn and Robert K. Merton (Chicago: University of Chicago Press, [1935] 1979). —— Cognition and Fact: Materials on Ludwik Fleck, ed. Robert S. Cohen and Thomas Schnelle (Dordrecht: Kluwer, 1986). Kuhn, Thomas S., The Structure of Scientific Revolutions (Chicago: University of Chicago Press, 1962). —— The Essential Tension: Selected Studies in Scientific Tradition and Change (Chicago: University of Chicago Press, 1977). Löwy, Ilana, Olga Amsterdamska, John Pickstone, and Patrice Pinell (eds), Medicine and Change: Historical and Sociological Studies of Medical Innovation (Paris: Les Éditions INSERM, 1993). Pickstone, John, Ways of Knowing: A New History of Science, Technology and Medicine (Manchester: Manchester University Press, 2000). Warner, John Harley, ‘The History of Science and the Sciences of Medicine’, Osiris, 10 (1995), 164–93.

chapter 27

women, hea lth, a n d m edici n e h ilary m arland

The theme women, health, and medicine warrants not a single chapter but an entire volume in order simply to sum up the state of scholarship in this diverse, energetic, and multifaceted area. The literature is vast and wide-ranging, growing exponentially decade on decade. From the 1970s onwards, the social history of medicine—as well as sociology, gender studies, and literary studies—has produced a flow of publications on the struggles of women to enter medicine and what they proceeded to do once they achieved this, on women as arbiters of health care in the home, on midwives and the politics of childbirth, on the evolution of the modern nursing profession, and on women as subjects of medical treatment and health care. While this topic is not necessarily writ large in recent anthologies and surveys of the discipline as a whole, it forms robust sections of numerous undergraduate and postgraduate syllabuses, spawns lively workshops and conferences and engaging edited volumes, and remains into the twenty-first century one of the more politicized areas of inquiry within the history of medicine.1 Research into women’s engagement with medicine as sufferers, patients, and active agents in promoting care and services has concentrated most insistently upon the various branches of medicine concerned with female conditions and disorders, notably midwifery, obstetrics and gynaecology, birth control, and maternal and child welfare, while women’s interactions with psychiatry have also attracted considerable attention. From the eighteenth century onwards, commencing with the establishment of lying-in hospitals, and then women’s hospitals and maternity and child welfare clinics, specialist provision for women became increasingly associated with institutions, representing a move away from the private, domestic sphere. Women became objects of charitable aid, while the twentieth century saw the resolute intrusion of the state in female health matters. At the same time, women were conceptualized as a potentially lucrative clientele willing to pay for the attention of private medical practitioners, and, by the closing decades of the twentieth century, services offered by doctors that had little or no medical benefit, notably cosmetic surgery.

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The emergence of specialist disciplines and shifts in the location of practice, along with the often bruising encounters that took place within competitive marketplaces between female healers and suppliers of health care and ambitious medical practitioners eager to secure an ever larger section of the market, have attracted considerable interest in historical scholarship. So too has the issue of agency, be it the agency of medical practitioners in shaping treatment and creating or restricting options for care, or the agency of women as campaigners, practitioners of various kinds, or active patients. Interactions and agency will constitute the core theme of this chapter, which will also consider specialization, the marketplace, and sites of practice, focusing on the feminist writings of the 1970s through to more reflective revisionist forms of analysis that have marked the discipline in recent years. Some themes are conspicuous by their absence in this chapter, notably nursing, women’s entry into medicine, and occupational health.2 The chapter will draw examples chiefly from those contexts responsible for delivering the bulk of historical writing in this field, namely Britain, North America, and Europe, though the interaction of women and medicine in colonial contexts has also been a remarkably productive field of scholarship in recent years.

Women, gender, and danger Following the publication of Joan Scott’s influential article in 1986, which promoted the potential of the category of gender when considering systems of social or sexual relations, the history of medicine responded with a number of books exploring sex difference and employing gender as a means of signifying and exploring relations of power.3 Overall, however, it is fair to argue that emphasis has remained on exploring women’s experiences or that the categories of gender history and women’s history have been applied interchangeably. Few studies have engaged with comparisons of men and women as patients, though several have described situations of conflict and repression, particularly in connection with the history of childbirth, gynaecology, and psychiatry. However, thinking more critically about gender has encouraged an expansion in subject-matter and enabled a more creative engagement with ideas of agency and male/ female interactions around medicine. Gender analysis has also become complicated— in a constructive way—through its combination with other categories, predominantly class and race. What has marked the study of women, health, and medicine across all historical periods from the 1970s onwards is an interest in framing this relationship—expressed in medical writing as well as practice—in terms of prevailing social, cultural, and political forces. Women’s bodies and medicine’s interactions with women have been depicted as being particularly prone to ideologically driven interventions, be these accusations of witchcraft in the fifteenth and sixteenth centuries, ideals of domesticity and the strictures of patriarchal society in the nineteenth, or the imperatives of state, nation, and scientific motherhood in the twentieth. What also links historical writing on women’s

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health is the connectedness of a wide range of interest groups: neighbours, church, traditional healers and medical professionals, the state, pressure groups, and health campaigners. To a far, far greater extent than for male sufferers, historical writing has framed women’s bodies, particularly sick women’s bodies, as being at the hub of a wide range of debates on nature versus culture, rhetoric versus practice, driven by varied, and often conflicting, medical, cultural, and political viewpoints. Mary Poovey, for example, suggested how in the mid-nineteenth century: the debates provoked by chloroform . . . constitute a discourse of sexual politics in which the female body has been politicized . . . Once silenced, this body can serve as a token in disputes both within the medical profession and between this male profession and the community of female midwives that gave birth to obstetrics. But the very silence that authorizes these different medical practices also produces at the site of the reproductive female body an undecidability that is dangerous to the medical profession and its controlling operations.4

Ludmilla Jordanova has cautioned, however, against interpretations based around the idea of a one-dimensional construct aimed at the oppression of women, which assumes ‘clearcut power relations, takes a social relationship—in this case between men and women— and finds a basis for it in the distinction between nature and culture’.5 Meanwhile, historians are obliged to pay serious attention to the gap—often a yawning gap—between what doctors and patients said or wrote and what they actually did in practice. The notion that male interactions with women’s health issues were marked by the assumption that women’s bodies were not only different, but intrinsically volatile, unpredictable, secret, and potentially dangerous, be this the leaky, menstruating bodies of the early modern period, the ravenous nymphomaniacs of the nineteenth century, the sexually polluted, or simply the unpredictable, have shaped numerous studies over time and geographical space. The most fertile ground where ideas of dangerousness could take root and flourish was in relation to female sexuality, prostitution, and venereal disease.6 But this theme has permeated a much broader literature. While David Harley convincingly debunked the link between midwifery and witchcraft, many other studies link women’s bodies to danger. Laura Gowing has described a prevailing medical discourse in seventeenth-century England that denigrated the female body as leaky and inferior, leaving women open to a cruel patriarchy and subject to humiliating bodily examinations. Helen King’s study of green sickness or the disease of virgins has outlined the process through which a common disorder affecting young unmarried girls was conceived increasingly as a medical ‘problem’ to be cured by diet, exercise, bloodletting, and marriage, thus taking medical control of a disorder surrounded by mystique and embedded in female culture. Cathy McClive, meanwhile, has described the ‘uncertainty’ that extended across the whole process of pregnancy in early modern Europe, heightened by the fact that both body and language could conceal the truth; women’s narratives were mistrusted, their bodies more likely to conceal than their male counterparts.7 Studies of the nineteenth and twentieth centuries have emphasized the dangers attached to the female body in connection, in particular, with the fields of midwifery and

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public health, or the two combined. Joan Mottram and Anne Løkke have focused on the complexities of midwives’ work as public health agents in the contexts of Manchester and Denmark. Løkke argued that the use of midwives in the antiseptic campaign against puerperal fever was complicated by ‘the midwives’ centuries-old, but still precarious balance between being valued helpers and representatives of life’s dark forces’, while the act of birth itself was regarded as ‘unavoidable contact with chaos, disintegration, disorder and creation’. Added to this was the fact that the midwife belonged to the lower classes, which in general was associated with things unclean. In early-twentieth-century Manchester, midwives were expected to take public health into working-class homes, to teach hygiene and raise standards of care during the birth, when the mother was particularly vulnerable to infection. Yet midwives themselves were objects of regulations on hygiene and, as well as being ‘agents of the new public health, they were also among its objects’.8 In the United States, the already complex relationship between midwives and hygienic practice was further complicated by race. Black midwives were recruited as agents of public health, particularly in poverty-stricken Southern states, while their status and blackness made them dubious candidates for this mission, notorious for their ‘bags to show and bags to go’, which defined the gap between black midwives’ work as agents of public health and their inclination towards traditional practices steeped in danger for the women they attended.9 Susan Smith’s path-breaking study of public health initiatives on the part of African Americans between 1890 and 1950 explores successes in overcoming these associations through grass roots activism.10 Alison Bashford’s work on gender, embodiment, and Victorian medicine in Britain, which drew on cultural and feminist theory as well as medical history, successfully united several of these themes into a unique study of how different practitioners were involved in both discourse and practice about the pure and the polluted. Bashford explored, for example, the ways in which the nurse shifted from being characterized as ignorant, filthy, and disordered to be seen as chaste, pure, and orderly, yet, still Bashford suggested, in a state of ‘precarious purity’, always in need of further cleansing, with her moral purity also in constant jeopardy.11

Interactions and agency The flood of literature that appeared in the early 1970s produced largely by feminist historians and activists eager to link historical research with contemporary issues concerning women’s health care and interactions with the medical profession forms a clear historiographical starting point to the topic of women, health, and medicine. Such work fed into the movement where women sought empowerment over their own health, into the emerging ‘Our Bodies, Ourselves’ agenda.12 Much of this literature was polemical in tone and historical research was often overwhelmed by the broader mission to represent women as victims of medicine and its predominantly male practitioners. Witches, Midwives and Nurses, published in 1973 by Ehrenreich and English, became emblematic

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of this trend, declaring that ‘health care was the property of male professionals’, while women health workers were ‘a passive, silent majority’.13 This small booklet moved swiftly from the witchcraft trials of the Middle Ages and consequent suppression of female healers to the rise of the modern male physician and the creation of the ‘handmaiden’ nurse. Two other volumes produced by this team developed the themes of the sexual politics of sickness and healing and the role of advice literature in shaping women’s health matters. The authors noted not only male domination as a constant, but also changes in the context of this domination, reflected in the late Victorian shift from a physician-directed cult of invalidism, where ‘doctors would continue to view menstruation, pregnancy, and menopause as physical diseases and intellectual liabilities’, to new sets of expert strictures and restrictions placed on women in connection with housekeeping and the management of germs, and motherhood and child-rearing.14 In a period where the women’s movement sensitized many academics to inequalities in women’s position in society, the female patient–male physician relationship was represented, as described by Judith Roy in her essay on surgical gynaecology, as ‘patriarchal society writ small’: ‘rejecting the old model of uncritical praise for “scientific medical progress”, the new studies emphasized cultural biases as major factors in women’s medical care’.15 Thus in 1976, G. J. Barker-Benfield denounced the gynaecological profession for their subconscious hostility and urge to subordinate women, emphasizing their use of mutilating surgery, notably clitoridectomy and ovariotomy, as playing out their sexual aggression.16 In 1982, Edward Shorter attempted to turn the tables. While arguing that ‘women’s bodies’ did have a history of their own, he countered feminist accounts, arguing that until modern obstetrics and gynaecology rescued women they were victims of botched deliveries and gynaecological diseases.17 Despite some shortcomings, particularly the scant regard of some feminist studies for scholarly protocols and source-based research, this literature provided an enormous stimulus to research on women’s relationship with medicine, pinpointing challenging areas and presenting material on topics where little work had appeared, at a moment when it is fair to say that the history of medicine was still largely dominated by the notion of medicine as progressive and (male) physician-oriented.18 This move was to dovetail with a growing interest in other neglected groups within medicine, the patient first and foremost, but also workers, the colonized, migrant groups, and non-white populations. Roy Porter’s timely plea to explore medical history ‘from below’ outlined a new agenda for medical historians—the exploration of the patient’s view, which, perhaps more implicitly than explicitly, included the brief to focus on women patients, as well as to open up the broader role of families and communities in steering medical interactions.19 Barbara Duden’s groundbreaking study in many ways still stands alone in the quality of its response to the call to explore patient history from below, opening up the world of Johann Storch and his patients in eighteenth-century Germany, revealing the ways in which women communicated accounts of their complaints in their own words. Duden’s work served to realign the history of the female body, indicating the power of women’s own agency in guiding medical consultations, which often took place without a direct physical examination.20 Meanwhile, a body of new historical work was emerging,

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inspired still by feminist or gender studies but based, as was Duden’s work, on close archival research and specific case studies, inclined to take a more measured view of the complexities of male–female medical interactions. This was still chiefly preoccupied with the relationship between physicians and their female patients—and their power relations—and was particularly embedded in the areas of obstetrics, gynaecology, and psychiatry. Appearing within a volume of essays eager to position issues of gender alongside those of class, social inequality, and race, Regina Markell Morantz’s piece marked a shift towards revisionist forms of analysis.21 Morantz’s ‘The Perils of Feminist History’, largely a critique of Ann Douglas Wood’s essay in the same volume, cautioned against an oversimplification of the interactions of women with medicine and advised scholars to place the treatment of women’s diseases in the past in the context of the medical therapeutics of the day. Douglas Wood, pitching ideology as reality and drawing on a series of breathtaking quotations from the highly polemical literature of the late nineteenth century, was at pains to stress the ways in which doctors ‘directed their attention to the womb in a way that seems decidedly unscientific and even obsessive to a modern observer’.22 For Markell Morantz this missed the ‘immense complexities’ that lay at the root of Victorian attitudes towards women.23 Anne Digby suggested further considerations in thinking about the relationship between women and medicine, arguing that rather than being strongly tied to patriarchal Victorian society, already by 1700 women were being stereotyped as frail and unstable, ‘medically unique but inferior . . . whose health was determined by her femininity’. These ideas, however, gained particular resonance from the mid-nineteenth century onwards, spurred by growing professional interest in the diseases of women, particularly in connection to the emerging specialisms of gynaecology and psychiatry and the adoption of a more overtly political stance by individual doctors who invested in ideas of gender difference, as women, challenging traditional roles, campaigned to enter public life and higher education. Medical literature, however, displayed ‘a striking contrast between its sound empirical observation and the extreme inferences that were drawn from it’.24 Nonetheless, as Cynthia Eagle Russett has suggested, white male scientists, doctors, and thinkers spent a large portion of the nineteenth century earnestly attempting to prove women inferior to men, mentally, morally, and physically.25 The years 1989–90 marked an extraordinary two years for the production of volumes on gender, sex, and difference, seeing the publication of Thomas Laqueur’s highly influential study of the demarcation of difference between the one-sex and two-sex models and Londa Schiebinger’s impressive survey of women’s contributions to the development of early modern science and medicine.26 It also saw the publication of Ornella Moscucci’s study of the emergence of the specialism of gynaecology, which she situated resolutely in a political context.27 But because she was keen to explore both ideology and practice, and undertook close archival research into several of the institutions buying into the ‘new science of woman’, the product was complex and nuanced. Moscucci pointed, for example, to the debates that divided gynaecologists into keen investigators and operators and those who, concerned with good practice and the preservation of

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female modesty, kept examinations and surgical interventions to a minimum. She began her study significantly by alluding to Thomas Spencer Wells’s attack against ‘gynaecological proletarians’ and the rampant removal of women’s ovaries. Would anyone, Wells commented, ‘Strip off the penis for a stricture or a gonorrhoea, or castrate a man because he has a hydrocele, or was a moral delinquent?’28 One would not wish to deny or diminish the horrors inflicted on women’s bodies by gynaecological surgery.29 Yet this quote is significant, and not solely for its dark humour and controversial nature; it also directs us to be alert to the range of views being put forward by medical men concerning women’s bodies. T. C. Allbutt sensationally declared in 1884: ‘Arraign the uterus and you fix in the woman the arrow of hypochondria, it may be for ever’.30 Some historical accounts could be accused of similar practices. Emphasis began to shift through the 1980s from surveying assertions of professional and patriarchal authority to focus on what we could broadly describe as ‘agency’. Ideas of agency centred on negotiations between male and female practitioners to delineate spheres of practice as well as on the demands of women patients. Women seeking, and oftentimes struggling, to enter medicine justified their efforts in part at least on the grounds of a growing need and demand on the part of women for the specialized care that women doctors were best suited to supply. In practice—at least one study has postulated—the care they offered did not necessarily differ that much from that of male practitioners. Morantz and Zschoche’s subtle analysis of the influence of professionalism, feminism, and gender roles in two late-nineteenth-century Boston hospitals, the New England Hospital staffed by women and the Boston Lying-In staffed by men, pointed to a dovetailing rather than divergence in clinical practice, though male practitioners embraced a more modern, technocratic approach to their patients, while women practitioners developed more holistic orientations.31 Mary Ann Elston has argued that by the 1930s a case could still be made for women-staffed hospitals as valuable providers of postgraduate education that ensured effective career routes for women doctors, but the justification was increasingly one of pragmatic strategy, necessity, rather than reflecting a moral principle, echoing Virginia Drachman’s findings for US women-run hospitals.32 Lesley Hall, however, has pointed out that in terms of birth control, despite general hostility and neglect of the topic by male practitioners, women doctors were prepared to get involved in this work in relatively large numbers in their private practices and in clinic work.33 Alternative medical practice too provided women with agency, training, employment, and income. This subject attracted a good deal of interest in the 1980s, but has waned somewhat since and the sum total of publications on women’s contributions to these forms of practice remains scant, particularly outside of the United States.34 Yet, research into alternative practices involving women has the potential to tell us more about women’s health aspirations and what they wanted from medicine and its alternatives. Hydropathy, for example, was taken up by large numbers of women, who practised at water-cure centres as well as within the home; it permeated child-care practices and appears to have provided opportunities for women to function as active agents in the birth process.35 And as Kathryn Gleadle has recently argued, it provided women, along-

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side other alternative systems of medicine, such as herbalism, medical botany, and vegetarianism, with empowerment in both public and private spheres.36 Women’s relationship with psychiatry has been one of the most energized areas of scholarship within the history of medicine since Ehrenreich and English and Phyllis Chesler, bolstered by anti-psychiatry’s presentation of psychiatry as a blunt instrument of social control, argued that the repressive control of psychiatry led to the exercise of power by male doctors over women.37 Many studies have focused on the nineteenth century and the process of building asylums and putting women in them; others have been located in the more intimate sphere of domestic interactions between doctors and patients, including a rich literature on the culture of the invalid.38 Elaine Showalter’s compelling and influential book The Female Malady dominated reading lists on women and madness for many years. Showalter concluded that psychiatry was propelled largely by notions of proper feminine behaviour and anxieties about any infringement of these, as well as by biological interpretations of the female condition, which closely linked body to mental state. In recent decades, other scholars have sought to nuance and challenge Showalter’s arguments.39 Joan Busfield’s study of madness and gender demonstrated how gender permeated constructions of mental disorder more broadly, with men and women manifesting different kinds of problems; she also questioned Showalter’s assertion that more women than men were incarcerated in institutions.40 A collection of essays edited by Andrews and Digby also presented case studies of local contexts and individual asylums, asserting that it is gender that should be analysed rather than the relationship between women and psychiatry in isolation and stressing the role of social class in determining how groups and societies responded to the mentally ill.41 Thus David Wright was able to argue, using data collected from the Buckinghamshire Lunatic Asylum, that women were institutionalized in numbers commensurate to their representation in the adult population, that women were not necessarily certified by male informants, and that gender did not appear to play a dominant role in psychiatric diagnosis.42 The asylum could act as a refuge for poorer women, while many psychiatrists were prepared to attribute ‘blame’ for particular disorders with husbands who were brutal, drunkards, or simply poor providers—in such cases patriarchy appears to be writ very small.43 Turning to diagnosis, even in the case of disorders particularly associated with the female life cycle, such as puerperal insanity, recent work has argued that female vulnerability to mental illness was rooted by psychiatrists in a wide range of social, economic, and circumstantial situations: poverty, domestic difficulties, and the despair that motherhood itself could provoke were invoked as causes, rather than purely—or even mainly—biological predisposition.44 It could be argued that the history of psychiatry has produced an over-abundance of work on women’s interactions with the profession, distorting findings. Men have fared less well as subjects of analysis, but when they do appear, as in the studies above and in a recent article by Akihito Suzuki, the indications are that there were many parallels in terms of the diagnosis and construction of male insanity.45 The interaction of private practitioners with patients suffering from hysteria and neurasthenia seems an unlikely arena for a discussion of agency. Yet increasing emphasis on

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the agency of the women in these relationships has strongly informed recent scholarship. It has been argued, for example, by Carroll Smith-Rosenberg, that doctors could respond to hysteria by offering time to recover, functioning as mediators for their female patients and enabling them to negotiate their positions and roles within families.46 Nancy Theriot has taken this further, suggesting that women contributed to the formation of medical knowledge and the shaping of disease categories, as well as ‘forging a sense of body and self ’: In telling their doctors about their complaints, they constructed themselves as people separate from their roles. By encouraging them to talk and legitimizing their illness symptoms, physicians aided them in this self-role separation and gave patients permission to avoid household chores; to preserve part of the day for exercise or quiet; to express hostility towards husbands, children, and in-laws; and to leave their families for temporary rest in asylums and spas.47

Recent studies have highlighted too how far from being restricted to the wealthy, both male and female working-class patients presented with, and were treated for, symptoms of neurasthenia, reminding us of the importance of maintaining social class as a category of analysis.48 Midwifery remains one of the most illuminating areas for exploring relationships between male and female practitioners and their patients, particularly when linked to the, still largely unresolved, question of why, during the course of the eighteenth and nineteenth centuries, there was such a dramatic shift away from midwives towards male practitioners as providers of obstetric care in what constitutes a major turning point in a broader process of ‘medicalization’. Martin Dinges has pointed out that midwives have been and still are ‘a major focus for understanding power and gender in the medical market’.49 Research in this area has been hampered by the limited range of primary sources on midwives themselves, women who, with a few notable exceptions, left little behind in the way of books, personal reflections, and case records. However, local studies based on close archival reading as well as surveys of official records can do much to address these absences.50 Meanwhile, Mary Fissell and Lisa Cody focused their studies on ‘representations’ of midwifery and medical knowledge. Fissell has suggested that the political and religious crises of the early modern period urged medical men to ‘re-imagine’ the female body, a process that undermined female knowledge and control, while Cody mapped the development of the modern British nation alongside the emergence of the male expert as the pre-eminent authority over matters of sexual behaviour, reproduction, and childbirth, particularly in elite and middle-class homes.51 A number of theses have been put forward to explain the shift from female to male practice, which represented a broad cultural as well as marketplace turn, taking mothers-to-be from a lying-in room notable for its occupation by female helpers and supporters, directed by the midwife, to a situation of isolation where they would be aided solely by a male attendant, possibly assisted by a midwife or nurse. The story, however, is more complex than a simple male takeover and destruction of female self-help traditions. Doreen Evenden has provided a close exploration of the complex networks

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between ecclesiastical licensing, midwives, and their clients in seventeenth-century London, describing high levels of female (and male) knowledge that determined arrangements for deliveries, while Ann Hess’s work has also indicated the significance of the involvement of husbands in directing childbirth arrangements.52 Adrian Wilson compellingly ascribed the process of change to ‘fashion and forceps’, whereby male midwives were able to claim technical authority to safely deliver babies (though the debate surrounding the value of forceps was enduring), as well as social authority that placed book learning and professional demeanour above tradition.53 Yet Wilson fails to provide conclusive evidence on women’s involvement in this process and how they exercised their capacity to choose. Irvine Loudon’s survey of the relationship between midwifery care and maternal death is exceptional in terms of its global reach.54 However, it is edited volumes that have allowed for the exploration of diversity in terms of many aspects of medical practice for and by women, enabling researchers to produce comparative work on local or national contexts across particular time frames. The English model, together with studies of the United States and Australasia, tended to dominate the literature until the 1990s—but in many senses midwifery practice in these contexts was atypical. The Art of Midwifery, with articles on a range of European and Scandinavian countries, concluded that the early modern period, far from being a golden age for midwives and those they attended, was an era marked by enormous variety in practices, competence, skills, education, ambition, and success. Closely textured comparative surveys of midwifery practice, incorporating interdisciplinary analyses and approaches, have produced increasingly subtle interpretations of the medicalization process.55 Midwives in some contexts were keen to expand their competence to use instruments, a factor that needs to be considered alongside midwives’ claims to be defenders of normal childbirth.56

Sites of practice Aside from midwifery practice, which has constituted a particularly fertile area of scholarship in terms of thinking about actors and processes within the marketplace, the activities of women have otherwise featured modestly in surveys of the medical marketplace as suppliers and consumers, warranting sections of books and articles but rarely comprehensive studies. Notable exceptions include Doreen Evenden’s survey of women’s role in Stuart medicine, Margaret Pelling’s work on female practice in early modern England, and Anne Digby’s analysis of the significance of female clients in opening up new markets to doctors in the nineteenth century.57 Though there is a growing body of literature on female-centred medical services, including lying-in hospitals, women’s hospitals, and birth control clinics, there is also considerable scope for further studies of individual institutions and locales. Existing studies, emphasizing motivation and agency, have argued that such institutions were set up not necessarily to answer any ideological imperatives, but to meet what was perceived as a real and urgent need to

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improve the lives of numerous women whose access to private medical care was limited. These studies have also led to deeper consideration of the role of social class as a crucial factor in mediating relationships between doctors and female patients.58 Though surveys of institutional care are vital in identifying the provision of services and the reasoning behind the establishment of particular facilities, if we agree that until fairly recently most medical interactions involving women took place in the home, then it is to domestic settings that historical researchers must also turn, a theme that Johanna Geyer-Kordesch was at pains to emphasize, arguing that women’s domestic activities formed the backbone of health care, including as it did medical treatment and nursing, the preparation and provision of food, and taking care of the home environment.59 An increasing body of scholarship is exploring medical interactions of various kinds within the context of the household, including the production of recipe books, sources that tell us a great deal about household medicine in general and the role of women in particular, as well as indicating the complexities surrounding the transmission of medical knowledge.60 While emphasis has remained very much with the early modern period, there appears to be considerable scope too for examining women’s health roles in the nineteenth- and twentieth-century home, and it is not unreasonable to argue that women remain chief arbiters of domestic health care today. The case was made convincingly as far back as 1975 by Patricia Branca in her study of middle-class women in the Victorian home, which drew on published health advice literature material produced specifically for married women. This, she concluded, led not necessarily to increased medical influence over domestic practices, but to women being equipped to better determine care in the home, where they also controlled expenditure on health care.61 A more recent study has highlighted the potential for exploring the interconnectedness of health and environment in the modern home in connection with mental health, cleanliness, allergies, and urban ecology.62 Given the production of a vast range of microfilm collections and electronic resources in recent years, the potential to utilize printed media, magazines, newspapers, and advice literature, with the view to discovering much more about health care in domestic settings, is an intriguing prospective. Recent studies have also turned to other ‘non-medical’ sites of health intervention for women, including girls’ schools, the factory, and sporting clubs and organizations, involving a wider range of agents and experts aside from doctors.63 Undoubtedly, however, the shift in emphasis in many aspects of women’s health from the private sphere of home and the family to the arena of state medicine was one of the most marked changes of twentieth-century medicine. This period saw the rise of national health services, national insurance schemes, and a plethora of policy-related interventions, in areas as diverse as birth control and family planning, midwifery services and school medicine. The dovetailing of state interests with medicine has been clearly elucidated in John Pickstone’s account of the political economy of twentiethcentury medicine, which outlined three phases of production, community, and consumption.64 Though his piece engaged only slightly with women and health, it highlighted how during the productionist phase of the early-twentieth-century anxieties about maternal and foetal health were heightened, centring upon concerns about

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the state of national health and its future in terms of bringing up reinforcements for the battlefield and factory. This was marked too in recent decades with a surge in literature on the topic of infant and maternal health, an area that produced—if not exactly comparative studies—a series of volumes drawing together experiences in a wide variety of national and international settings.65 Much literature examining the health of women in the twentieth century has focused on the notion that the primary objective of state intervention was to ensure reproductive health, which according to Barbara Harrison was the ‘single issue’ that dominated interest in women’s health, the ‘health of the physical body of the nation’ and ‘the social body, and the extent to which women’s health could be used as a political strategy to maintain a sexual division of labour in the public domains of work and education’.66 This rather narrow interpretation has been critiqued in recent work. Long and Marland have argued that there was a much broader set of anxieties concerning the health of young, unmarried women during the early twentieth century. Interventions by government and voluntary agencies targeted hygiene, general well-being, exercise, fashion and beauty, and psychological health, much of this concerned with producing morally sound and productive future citizens, as well as aiming to raise the general standards of health amongst girls.67

Conclusion Aside from state incursions and the stepped-up role of the voluntary sector, the twentieth century has been framed as a period of intensified medicalization, a process that impacted strongly on women in terms of the shift from home to hospital births, the increased application of childbirth technologies, and the rise of what has been labelled, particularly in the United States, scientific motherhood. The idea of women’s health issues being increasingly dominated by scientific medicine harks back to the early writings of Ehrenreich and English, and one of the best-known elucidations of the impact of medicalization is Ann Oakley’s The Captured Womb, which was sharply critical of what she described as the male takeover of pregnancy and childbirth.68 In the hands of historian Nancy Tomes, the issue of medicalization took on more subtle resonances, as she argued that germ theory served not to make women’s lives burdensome, but reinvented housework as an activity that involved women in important work maintaining the health of their families in the home.69 Rima Apple’s influential studies have focused on the dovetailing of physician power in the area of infant feeding in the United States with the emergent infant food industry and the dissemination by the mass media of ‘scientific’ solutions to problems of daily life. Other work has explored the role played by experts— notably Frederic Truby King (1858–1936) and Benjamin Spock (1903–98)—in shaping the practices and ideologies of motherhood in powerful ways.70 Yet families could, Lyubov Gurjeva has argued, evolve their own hierarchies of concern in connection with infant-rearing, and the advice of experts merely bolstered their own aspirations. More recently, Angela Davis has questioned the impact of professional advice literature on

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mothers, maternity, and practices of child-care in post-1945 Britain, arguing for the continued importance of lay knowledge.71 Davis’s work signals two significant shifts in terms of emerging areas of research, one methodological, the second related to historical time frames. Oral history is developing as an ever more valuable tool as increasing numbers of projects shift their focus to the twentieth century, in particular the post-war period. Oral history approaches have been applied with particular effectiveness to work on family planning and contraception, sexuality, and the gendering of depression.72 Meanwhile, research on women, gender, and health is considering an ever wider range of historical categories—class and social inequality, race, age, and ethnicity—as well as integrating interdisciplinary approaches, drawing on such fields as social geography, migration studies, and philosophy, in part at least in response to calls to engage more robustly with ‘medical humanities’. As the history of old age and childhood and adolescence has boomed in recent decades, this provides new opportunities to explore the relationship between life cycle and women’s health in new and exciting ways. Over recent decades a number of keynote studies have assessed how ethnicity intersected with various forms of cultural and institutional practices, in maternity care, midwifery, and psychiatry, for example, but multiple opportunities remain to develop this theme further.73 Future challenges are also offered through active engagement with current concerns regarding women, health, and medicine at a time of global recession and cuts in health services, which are taking place alongside expanding knowledge and opportunities within medicine, for example, in reproductive medicine, which raises important ethical issues as well as questions of entitlement and funding. And as we see on an almost daily basis in media reports, attention remains with welfare mothers and issues of female body shape and weight, as female health problems continue to be firmly embedded in broader cultural, social, and political ideologies and practices. Concerns about the power of medicine over women’s health issues drove the rise of early historical research on women and medicine, and in many ways it continues to drive it today. Work on cancer, reproductive health, health education, sexual health, and fertility, for instance, all engage with areas of current concern in terms of women’s health matters. The shift in emphasis to more recent history is an exciting one. We already know a good deal about maternity care up until the interwar years, but little beyond that. We have a large body of research on women’s relationship with psychiatry in the nineteenth century but less on the twentieth. In terms of birth control, research into the impact of the pill has suggested that rather than ushering in a sexual revolution, the 1960s was a period marked for most women by sexual and cultural conservatism, but few studies have explored techniques of contraception and how they were used by different groups of women in different contexts in the later decades of the twentieth century. Increasingly, during the late nineteenth and twentieth centuries women constituted themselves as health activists, engaging with the formation of health policies or shaping them, and the time seems ripe to revisit women’s health activism and feminist health politics as representing important historical moments in their own right.

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Notes 1. For example, neither Frank Huisman and John Harley Warner (eds), Locating Medical History: The Stories and Their Meanings (Baltimore/London: Johns Hopkins University Press, 2004), nor Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (London: Harwood International, 2000), engaged substantially with women and medicine or gender and medicine. 2. See Johanna Geyer-Kordesch, ‘Women and Medicine’, in W. F. Bynum and Roy Porter (eds), Companion Encyclopaedia of the History of Medicine, vol. 2 (London/New York: Routledge, 1992), 888–914, for nursing and women doctors. 3. Joan Scott, ‘Gender: A Useful Category of Historical Analysis’, American Historical Review, 91 (1986), 1053–76; Thomas Laqueur, Making Sex: Body and Gender from the Greeks to Freud (Cambridge, MA: Harvard University Press, 1990); Alison Bashford, Purity and Pollution: Gender, Embodiment and Victorian Medicine (Basingstoke: Macmillan, 1998); Lesley A. Hall, Sex, Gender and Social Change in Britain since 1880 (Basingstoke: Macmillan, 2000). 4. Mary Poovey, ‘ “Scenes of an Indelicate Character”: The Medical “Treatment” of Victorian Women’, Representations, 14 (1986), 137–68, at 152. 5. Ludmilla Jordanova, Sexual Divisions: Images of Gender in Science and Medicine between the Eighteenth and Twentieth Centuries (New York: Harvester Wheatsheaf, 1989), 20–1. 6. See Chapter 28, ‘Health and Sexuality’, by Gayle Davis in this volume. 7. David Harley, ‘Historians as Demonologists: The Myth of the Midwife-Witch’, Social History of Medicine, 3 (1990), 1–26; Laura Gowing, Common Bodies: Women, Touch and Power in Seventeenth-Century England (New Haven, CT/London: Yale University Press, 2003); Helen King, The Disease of Virgins: Green Sickness, Chlorosis and the Problems of Puberty (London/New York: Routledge, 2004); Cathy McClive, ‘The Hidden Truths of the Belly: The Uncertainties of Pregnancy in Early Modern Europe’, Social History of Medicine, 15 (2002), 209–27. 8. Anne Løkke, ‘The “Antiseptic” Transformation of Danish Midwives, 1860–1920’, in Hilary Marland and Anne Marie Rafferty (eds), Midwives, Society and Childbirth: Debates and Controversies in the Modern Period (London/New York: Routledge, 1997), 102–33, at 126; Joan Mottram, ‘State Control in Local Context: Public Health and Midwife Regulation in Manchester, 1900–1914’, in ibid. 134–52, at 147. 9. Edward H. Beardsley, ‘Race as a Factor in Health’, in Rima Apple (ed.), Women, Health, and Medicine in America (New Brunswick, NJ: Rutgers University Press, 1992), 121–40. 10. Susan L. Smith, Sick and Tired of Being Sick and Tired: Black Women’s Health Activism in America, 1890–1950 (Philadelphia: University of Pennsylvania Press, 1995). 11. Bashford, Purity and Pollution. 12. First published in 1973, Our Bodies, Ourselves has passed through twelve editions, containing information related to many aspects of women’s health and sexuality: Alexandra Jacobs, ‘A Feminist Classic Gets a Makeover’, review, New York Times (17 July 2005). 13. Barbara Ehrenreich and Deirdre English, Witches, Midwives and Nurses (Old Westbury, NY: The Feminist Press, 1973), 19. 14. Barbara Ehrenreich and Deidre English, Complaints and Disorders: The Sexual Politics of Sickness (Old Westbury, NY: The Feminist Press, 1973); eaedem, For Her Own Good: 150 Years of the Experts’ Advice to Women (New York: Anchor Press/Doubleday, 1978), 126. 15. Judith Roy, ‘Surgical Gynecology’, in Apple (ed.), Women, Health and Medicine, 173–95, at 177.

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16. G. J. Barker-Benfield, The Horrors of the Half-Known Life (New York: Harper and Row, 1976). 17. Edward Shorter, A History of Women’s Bodies (New York: Basic Books, 1982). 18. See the essays in Huisman and Warner (eds), Locating Medical History, especially Part II. 19. Roy Porter, ‘Doing Medical History from Below’, Theory and Society, 14 (1985), 175–98. 20. Barbara Duden, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany (Cambridge, MA/London: Harvard University Press, 1991). 21. Regina Markell Morantz, ‘The Perils of Feminist History’, in Judith Walzer Leavitt (ed.), Women and Health in America (Madison: University of Wisconsin Press, 1984), 239–45. 22. Ann Douglas Wood, ‘ “The Fashionable Diseases”: Women’s Complaints and Their Treatment in Nineteenth-Century America’, in Leavitt (ed.), Women and Health in America, 222–38, at 223. 23. Markell Morantz, ‘The Perils of Feminist History’, 239. 24. Anne Digby, ‘Women’s Biological Straitjacket’, in Susan Mendus and Jane Rendall (eds), Sexuality and Subordination: Interdisciplinary Studies of Gender in the Nineteenth Century (London/New York: Routledge, 1989), 192–220, at 192, 193, 194. 25. Cynthia Eagle Russett, Sexual Science: The Victorian Construction of Womanhood (Cambridge, MA/London: Harvard University Press, 1989). 26. Laqueur, Making Sex: Body and Gender from the Greeks to Freud; Londa Schiebinger, The Mind Has No Sex? Women in the Origins of Modern Science (Cambridge, MA/London: Harvard University Press, 1989). 27. Ornella Moscucci, The Science of Woman: Gynaecology and Gender in England 1800–1929 (Cambridge: Cambridge University Press, 1990). 28. Ibid. 7. 29. See also Ann Dally, Women Under the Knife: A History of Surgery (London: Hutchinson Radius, 1991); Deborah Kuhn McGregor, From Midwives to Medicine: The Birth of American Gyneocology (New Brunswick, NJ/London: Rutgers University Press, 1998); Pat Jalland and John Hooper, Women from Birth to Death: The Female Life Cycle in Britain 1830–1914 (Brighton: Harvester Press, 1986). 30. Cited in Digby, ‘Women’s Biological Straitjacket’, 195. 31. Regina Markell Morantz and Sue Zschoche, ‘Professionalism, Feminism, and Gender Roles: A Comparative Study of Nineteenth-Century Medical Therapeutics’, in Leavitt (ed.), Women and Health in America, 406–21, esp. 415. See also Regina Markell MorantzSanchez, Sympathy and Science: Women Physicians in American Medicine (New York/ Oxford: Oxford University Press, 1985). 32. Mary Ann Elston, ‘ “Run by Women, (Mainly) for Women”: Medical Women’s Hospitals in Britain, 1866–1948’, in Anne Hardy and Lawrence Conrad (eds), Women and Modern Medicine (Amsterdam/New York: Rodopi, 2001), 73–107, at 97; Virginia Drachman, Hospital with a Heart: Women Doctors and the Paradox of Separatism at the New England Hospital, 1862–1969 (Ithaca: Cornell University Press, 1984). 33. Lesley A. Hall, ‘A Suitable Job for a Woman: Women Doctors and Birth Control to the Inception of the NHS’, in Hardy and Conrad (eds), Women and Modern Medicine, 127–47. 34. Naomi Rogers, ‘Women and Sectarian Medicine’, in Apple (ed.), Women, Health, and Medicine in America, 273–302.

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35. Jane B. Donegan, Hydropathic Highway to Health: Women and Water-Cure in Antebellum America (New York: Greenwood Press, 1986); Susan E. Cayleff, Wash and Be Healed: The Water-Cure Movement and Women’s Health (Philadelphia: Temple University Press, 1987); Hilary Marland and Jane Adams, ‘Hydropathy at Home: The Water Cure and Domestic Healing in Mid-Nineteenth-Century Britain’, Bulletin of the History of Medicine, 83 (2009), 499–529. 36. Kathryn Gleadle, ‘ “The Age of Physiological Reformers”: Rethinking Gender and Domesticity in the Age of Reform’, in Arthur Burns and Joanna Innes (eds), Rethinking the Age of Reform: Britain 1780–1850 (Cambridge: Cambridge University Press, 2003), 200–19. 37. Phyllis Chesler, Women and Madness (New York: Doubleday, 1972). 38. Maria H. Frawley, Invalidism and Identity in Nineteenth-Century Britain (Chicago/ London: University of Chicago Press, 2004); Jane Wood, Passion and Pathology in Victorian Fiction (Oxford: Oxford University Press, 2001). 39. Elaine Showalter, The Female Malady: Women, Madness and English Culture, 1830–1980 (London: Virago, 1987; 1st published New York: Pantheon, 1985). 40. Joan Busfield, Men, Women and Madness: Understanding Gender and Mental Disorder (Basingstoke: Macmillan, 1996). 41. Jonathan Andrews and Anne Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam/ New York: Rodopi, 2004). 42. David Wright, ‘Delusions of Gender?: Lay Identification and Clinical Diagnosis of Insanity in Victorian England’, in Andrews and Digby (eds), Sex and Seclusion, Class and Custody, 149–76. 43. Hilary Marland, Dangerous Motherhood: Insanity and Childbirth in Victorian Britain (Basingstoke: Palgrave Macmillan, 2004). 44. Ibid.; Nancy Theriot, ‘Diagnosing Unnatural Motherhood in Nineteenth-Century Physicians and “Puerperal Insanity”’, in Judith Walzer Leavitt (ed.), Women and Health in America, 2nd edn (Madison: University of Wisconsin Press, 1990), 405–21. 45. Akihito Suzuki, ‘Lunacy and Labouring Men: Narratives of Male Vulnerability in MidVictorian London’, in Roberta Bivins and John V. Pickstone (eds), Medicine, Madness and Social History: Essays in Honour of Roy Porter (Basingstoke: Palgrave Macmillan, 2007), 118–28. 46. Carroll Smith-Rosenberg, ‘The Hysterical Woman: Sex Roles and Role Conflict in 19th Century America’, Social Research, 39 (1979), 652–78. 47. Nancy Theriot, ‘Negotiating Illness: Doctors, Patients and Families in the Nineteenth Century’, Journal of the History of Behavioral Sciences, 37 (2001), 349–68, at 363–4. 48. Barbara Sicherman, ‘The Use of a Diagnosis: Doctors, Patients, and Neurasthenia’, Journal of the History of Medicine, 32 (1977), 33–54; Hilary Marland, ‘ “Uterine Mischief ”: W. S. Playfair and His Neurasthenic Patients’, in Marijke Gijswijt-Hofstra and Roy Porter (eds), Cultures of Neurasthenia from Beard to the First World War (Amsterdam/New York: Rodopi, 2001), 117–39. 49. Martin Dinges, ‘Social History of Medicine in Germany and France in the Late Twentieth Century: From the History of Medicine Toward a History of Health’, in Huisman and Warner (eds), Locating Medical History, 209–36. 50. Justine Siegemund: The Court Midwife, ed. and trans. Lynne Tatlock (Chicago/London: University of Chicago Press, 2005); Nina Rattner Gelbart, The King’s Midwife: A History

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51.

52.

53. 54. 55.

56.

57.

58.

59. 60.

hilary marland and Mystery of Madame du Coudray (Berkeley/Los Angeles/London: University of California Press, 1998); Laurel Thatcher Ulrich, A Midwife’s Tale: The Life of Martha Ballard, Based on Her Diary, 1785–1812 (New York: Knopf, 1990); Jean Donnison, Midwives and Medical Men: A History of Inter-Professional Rivalries and Women’s Rights (London: Heinemann, 1977; 2nd edn, New Barnett: Historical Publications, 1988); Hilary Marland (ed.), The Art of Midwifery: Early Modern Midwives in Europe (London/New York: Routledge, 1993); Eva Labouvie, Ander Umstände: Eine Kulturgeschichte der Geburt (Cologne: Bohlau, 1998); Samuel S. Thomas, ‘Early Modern Midwifery: Splitting the Profession, Connecting the History’, Journal of Social History, 43 (2009), 115–38. Mary E. Fissell, Vernacular Bodies: The Politics of Reproduction in Early Modern England (Oxford: Oxford University Press, 2004); Lisa Forman Cody, Birthing the Nation: Sex, Science and the Conception of Eighteenth-Century Britons (Oxford: Oxford University Press, 2005). Doreen Evenden, The Midwives of Seventeenth-Century London (Cambridge: Cambridge University Press, 2000); Ann Hess, ‘Midwifery Practice among the Quakers in Southern Rural England in the Late Nineteenth Century’, in Marland (ed.), The Art of Midwifery, 49–76. Adrian Wilson, The Making of Man-Midwifery: Childbirth in England, 1660–1770 (London: UCL Press, 1995). Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800–1950 (Oxford: Clarendon Press, 1992). Marland (ed.), The Art of Midwifery; Raymond DeVries, Cecilia Benoit, Edwin van Teijlingen, and Sirpa Wrede (eds), Birth by Design: Pregnancy, Maternity Care, and Midwifery in North America and Europe (New York/London: Routledge, 2001). Christina Romlid, ‘Swedish Midwives and Their Instruments in the Eighteenth and Nineteenth Centuries’, in Marland and Rafferty (eds), Midwives, Society and Childbirth, 38–60; Hilary Marland, ‘Smooth, Speedy, Painless, and Still Midwife Delivered? The Dutch Midwife and Childbirth Technology in the Early Twentieth Century’, in Hardy and Conrad (eds), Women and Modern Medicine, 173–94. Doreen G. Nagy, Popular Medicine in Seventeenth-Century England (Bowling Green: Bowling Green State University Popular Press, 1988), Chapter 5; Margaret Pelling, ‘Defensive Tactics: Networking by Female Medical Practitioners in Early Modern London’, in Alexandra Shepard and P. J. Withington (eds), Communities in Early Modern England: Networks, Place, Rhetoric (Manchester: Manchester University Press, 2000), 38–53; Margaret Pelling, The Common Lot: Sickness, Medical Occupations and the Urban Poor in Early Modern England (London/New York: Longman, 1998); Anne Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911 (Cambridge: Cambridge University Press, 1994), Chapter 9. Jürgen Schlumbohm, ‘ “The Pregnant Women Are Here for the Sake of the Teaching Institution”: The Lying-In Hospital of Göttingen University, 1751 to c.1830’, Social History of Medicine, 14 (2001), 59–78; Judith Lockwood, ‘Women, Health and Hospitals in Birmingham: The Birmingham and Midland Hospital for Women, 1871–1948’, PhD thesis, University of Warwick, 2008. Geyer-Kordesch, ‘Women and Medicine’. Pelling, The Common Lot; eadem, ‘Defensive Tactics’; Montserrat Cabré, ‘Women or Healers? Household Practices and the Categories of Health Care in Late Medieval Iberia’, Bulletin of the History of Medicine, 82 (2008), 18–51; Elaine Leong, ‘Making Medicines in

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61. 62. 63.

64.

65.

66. 67. 68. 69. 70.

71.

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the Early Modern Household’, Bulletin of the History of Medicine, 82 (2008), 145–68; Elaine Leong and Sara Pennell, ‘Recipe Collections and the Currency of Medical Knowledge in the Early Modern “Medical Marketplace”’, in Mark S. R. Jenner and Patrick Wallis (eds), Medicine and the Market in England and Its Colonies, c.1450-c.1850 (Basingstoke: Palgrave Macmillan, 2007), 133–52; Sandra Cavallo et al., ‘Healthy Homes, Healthy Bodies in Renaissance and Early Modern Italy’, http://www.rhul.ac.uk/History/Research/ HealthyHomes/rensocamerica.html Patricia Branca, Silent Sisterhood: Middle-Class Women in the Victorian Home (London: Croom Helm, 1975). Mark Jackson (ed.), Health and the Modern Home (London: Routledge, 2007). Vicky Long and Hilary Marland, ‘From Danger and Motherhood to Health and Beauty: Health Advice for the Factory Girl in Early Twentieth-Century Britain’, Twentieth Century British History, 20 (2009), 454–81; Angela Woollacott, ‘Maternalism, Professionalism and Industrial Welfare Supervisors in World War I Britain’, Women’s History Review, 3 (1994), 29–36; Jill Matthews, ‘They Had Such a Lot of Fun: The Women’s League of Health and Beauty between the Wars’, History Workshop Journal , 30 (1990), 22–54; Kathleen E. McCrone, Sport and the Physical Emancipation of English Women 1870–1914 (London: Routledge, 1988). John Pickstone, ‘Production, Community and Consumption: The Political Economy of Twentieth-Century Medicine’, in Cooter and Pickstone (eds), Companion to Medicine in the Twentieth Century, 1–20. Gisela Bock and Pat Thane (eds), Maternity and Gender Policies: Women and the Rise of the European Welfare States, 1880s–1950s (London/New York: Routledge, 1991); Valerie Fildes, Lara Marks, and Hilary Marland (eds), Women and Children First: International Maternal and Infant Welfare 1870–1945 (London/New York: Routledge, 1992); Seth Koven and Sonya Mitchell (eds), Mothers of a New World: Maternalist Politics and the Origins of Welfare States (New York/London: Routledge, 1993). Barbara Harrison, ‘Women and Health’, in June Purvis (ed.), Women’s History: Britain, 1850–1945 (London: UCL Press, 1995), 157–92, at 182. Long and Marland, ‘From Danger and Motherhood to Health and Beauty’. Ann Oakley, The Captured Womb: A History of the Medical Care of Pregnant Women (Oxford: Basil Blackwell, 1984). Nancy Tomes, The Gospel of Germs: Men, Women and the Microbe in American Life (Cambridge, MA/London: Harvard University Press, 1998). Rima D. Apple, Mothers and Medicine: A Social History of Infant Feeding 1890–1950 (Madison: University of Wisconsin Press, 1987); Philippa Mein Smith, Maternity in Dispute: New Zealand 1920–1939 (Wellington: Historical Publications Branch Department of Internal Affairs, 1986). Lyubov Gurjeva, ‘Child Health, Commerce and Family Values: The Domestic Production of the Middle Class in Late-Nineteenth and Early-Twentieth Century Britain’, in Marijke Gijswijt-Hofstra and Hilary Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam/New York: Rodopi, 2003), 103–25; Angela Davis,‘A Revolution in Maternity Care? Women and Maternity Services, Oxfordshire c.1948–1974’, Social History of Medicine (2011), doi: 10.1093/shm/hkq092, accessed 17 March 2011; eadem, ‘ “When I Was Young You Just Went and Asked Your Mother”: The Changing Role of Friends and Kin in the Transmission of Knowledge about Maternity in Post-1945 Britain’, Medizin, Gesellschaft und Geschichte (forthcoming).

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72. See Chapter 33, ‘Oral Testimony and the History of Medicine’, by Kate Fisher in this volume. 73. Elizabeth Lunbeck, The Pyschiatric Persuasion: Knowledge, Gender and Power in Modern America (Princeton, NJ: Princeton University Press, 1994); Lara V. Marks, Model Mothers: Jewish Mothers and Maternity Provision in East London 1870–1939 (Oxford: Oxford University Press, 1994); Charlotte G. Borst, Catching Babies: The Professionalization of Childbirth, 1870–1920 (Cambridge, MA: Harvard University Press, 1995).

Select Bibliography ‘Women, Health, and Healing in Early Modern Europe’, special issue, Bulletin of the History of Medicine, 82 (2008). Andrews, Jonathan, and Anne Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam/ New York: Rodopi, 2004). Apple, Rima (ed.), Women, Health, and Medicine in America (New Brunswick, NJ: Rutgers University Press, 1992). Bashford, Alison, Purity and Pollution: Gender, Embodiment and Victorian Medicine (Basingstoke: Macmillan, 1998). Duden, Barbara, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany (Cambridge, MA/London: Harvard University Press, 1991). Evenden, Doreen, The Midwives of Seventeenth-Century London (Cambridge: Cambridge University Press, 2000). Leavitt, Judith Walzer (ed.), Women and Health in America, 2nd edn (Madison: University of Wisconsin Press, 1984, 1999). Marland, Hilary (ed.), The Art of Midwifery: Early Modern Midwives in Europe (London/ New York: Routledge, 1993). Showalter, Elaine, The Female Malady: Women, Madness and English Culture, 1830–1980 (London: Virago, 1987; 1st published New York: Pantheon, 1985). Theriot, Nancy, ‘Negotiating Illness: Doctors, Patients and Families in the Nineteenth Century’, Journal of the History of Behavioral Sciences, 37 (2001), 349–68.

chapter 28

h e a lth a n d sexua lit y g ayle davis

The history of sexuality has developed considerably from the ‘virgin field’ described in 1972.1 Once considered a ‘natural’ biological act somehow beyond analysis, or too obscene for legitimate researchers, sexuality is now clearly considered worthy of and amenable to historical analysis. The discipline has flourished into an established, respectable, and intellectually vibrant field of inquiry, with significant contributions from, amongst others, historians of demography, gender, and medicine, anthropologists, and sociologists. As a result, it is now characterized by rich methodological and interpretive diversity. The concept of sexuality is being deployed as a prism through which a rich range of social, cultural, and political issues can be explored. There is a dedicated journal, academic presses are welcoming, and university courses are commonplace. The history of sexuality has become ‘sexy’. Recent scholarship has attributed the discipline’s origins to the emergence of a latenineteenth-century science of sexuality (sexology) that described and categorized sexual behaviours and types. Subjects integral to sexuality, including procreation, were also incorporated into historical and anthropological inquiry at this time. However, as a formal scholarly enterprise, the history of sexuality did not gain widespread legitimacy until at least the 1950s, with Keith Thomas’s seminal article on ‘the double standard’, the pervasive historical differences in how sexual behaviour was viewed between the genders.2 The rise of social history in the late 1960s, inspired by social and political upheaval such as the civil rights and anti-psychiatry movements, legitimated the place of sexuality in historical scholarship. Its stated rationale was to study ordinary life and to recover the experiences of marginal, voiceless groups. Social history also promoted interest in the domestic sphere, with sexuality becoming one sector of a private world now considered worthy of exploration. The sexual radical movements began to undermine preconceptions of ‘natural’ gender roles and sexual attitudes. Feminism and gay liberation pointed to the pervasive patriarchal oppression of women and the endemic homophobia of Western culture. While some early scholars worked atheoretically, others conceptualized sexuality in psychoanalytical, neo-Freudian terms as a biological instinct shaped by culture. A key focus was Victorian sexuality, with scholars portraying the

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Victorians as highly repressive and repressed ‘modern Puritans’ compelled to dress even their table legs to protect their modesty.3 However, this ‘repressive hypothesis’ was challenged radically by the French philosopher and historian Michel Foucault, who argued that Freud’s insights were an integral part of Victorian moralism rather than an enlightened and liberating break from it.4 Moreover, in his account, the Victorians sanctioned, rather than silenced, a proliferation of discourses about sexuality, subjecting sexuality to classification and control through legal, medical, and psychological apparatuses. This ‘discursive explosion’ described and specified ‘normality’ and ‘abnormality’, and encouraged individuals to examine their own desires according to these new standards. Such insights fed into a wider account of power in Western history that inverted the story of progress.5 Foucault documented the rise of ‘bio-power’ (power over life), the abandonment of coercive instruments such as capital punishment to be replaced by more insidious ruling techniques so that individuals could be managed and rendered more productive. Medicine was arguably the primary network through which bio-power was exercised.6 Foucault asserted that sexual identities, such as the homosexual, sadist, and voyeur, were a recent historical phenomenon, the product of new medical and legal discourses. From the nineteenth century, the homosexual became a particular ‘type’ of person, a distinct species marked by peculiar habits of speech, thought, and dress as well as the sexual acts in which he indulged. For Foucault, sexuality was an invention of modernity, not because sexual acts and desires were not present previously, but because Victorian discourses marked a significantly new way of understanding and governing desire by making sexuality a problem that required investigation. Foucault’s theoretical approach has been widely contested, most notably by historians of race and gender who have highlighted those forms of oppression that he ignored. However, his work has also proved highly influential, setting a challenging research agenda for others to follow. Foucault made sexuality integral to the creation of the social power relations that characterized modernity. Moreover, he radically historicized sexuality, conceptualizing it as something shaped or created by society rather than a ‘natural’ force. He was thus explicitly rejecting previous ‘essentialist’ approaches, which characterized sexuality transhistorically as an immutable force or ‘natural instinct’, and seeking to undermine perceived sexual continuities across time and culture. Foucault’s work formed an important component of what became known as ‘social constructionism’. By the 1970s, the prevailing view—a constructionist outlook—was that sexuality was fundamentally social and historical rather than biological or natural, and that historical studies of sexuality required to be situated within a specific context. Debate between essentialists and constructionists over whether sexual identities in the past and between places were similar or radically different shaped much of the discipline during the 1980s and 1990s. Disputes were particularly lively in the rich and sometimes polemical field of gay and lesbian studies, informed by a strong desire to promote social justice. The field was also enriched by the growing discipline of women’s and gender history, which sought to integrate patterns of sexual behaviour into a wider analysis of power relations and women’s oppression.

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The discipline has been marked by increasing divergence. Many scholars have grappled with the theoretical legacies of Foucault and feminism, devoid in some cases of an empirical basis, and in others applying theoretical analysis selectively to empirical research. Other groups have distanced themselves from early theoretical dominance, adopting instead an entirely empirically based archival approach. The theoretically informed have, in some cases, unfairly characterized such work as merely ‘descriptive’; historically specific and well-contextualized empirical research has added much meat to the bones of theoretical sophistication and validated a range of theoretical insights. Ways of knowing about sexual attitudes and behaviours come to us through an increasingly rich diversity of primary sources, though the historian must tread carefully in such sensitive and secretive territory. Representations of gendered bodies and sexual acts have been reconstructed through fiction, medical textbooks, memoirs, and letters. Discourses of sexuality have been gleaned from records generated by institutions of governance and surveillance, particularly law and medicine. Sexual attitudes have been captured to some extent through didactic literature, sex surveys, diaries, and interviews. Court records and newspapers have shone the light of publicity into the recesses of private life.7 Evidence has tended to be more plentiful for forms of sexual behaviour regarded as transgressive. Much remains to be done where sexuality and medicine intersect. This might be expected given the private nature of medical consultations, though case notes and demographic data are now being exploited to reconstruct the life experiences of, for example, the syphilitic or sexually dysfunctional patient.8 Yet, most histories of sexuality are removed to some extent from the reality of everyday sexual relationships. With sex the quintessentially private act, most leave little trace of their sexual practices. Foucault’s over-determining influence has also diverted historiographic attention away from actual sexual behaviour. This chapter will consider the ways in which female and male sexualities have been constructed, problematized, and policed in modern Western history. The medical role will be stressed, bearing in mind the ambivalent historical relationship that existed between physicians, sexual science, and society. With reference to the ‘double standard’, it will be shown how female sexuality has been particularly prone to pathologization and psychiatrization when deemed to stray from the marital or reproductive ideal.

Female sexuality Prior to the Enlightenment, women appear to have been considered ‘inferior’ versions of men in medical terms, with men and women widely believed to represent two different forms of one essential sex, as represented by Laqueur’s ‘one-sex’ model.9 Women were understood to possess the same basic reproductive structures as men, with the genitalia instead placed inside the body and the vagina considered an internal penis and the ovaries as testicles. A fundamental change is seen to have occurred in European

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attitudes towards human sexual anatomy over the eighteenth century, or earlier,10 whereby the two sexes began to be seen as opposites. Nonetheless the female reproductive organs, concealed within the abdominal cavity, continued to present medical challenges. Such challenges encouraged the continued characterization of female biology as somehow problematic long after the death of the one-sex model. While previously women had been considered as sexual as men, the binary gender system allowed a separation of the sexes in terms of sexual behaviour. By the late eighteenth century, only male orgasm was believed crucial to conception, with ‘active’ sexuality henceforth considered a masculine trait. Physicians, clergymen, and novelists alike began to characterize active female sexuality as aberrant, with ‘normal’ women believed to lack carnal desire. Socially acceptable sexual activity was to take place within an exclusively marital context and ideally only for reproductive purposes, with chastity considered the pre-eminent female virtue. Such views of the passionless woman reflected wider ideals, with Victorian morality premised on a series of ‘separate spheres’ or ideological separations between wife and husband, home and work, the wholesome domestic environment and the polluting public sphere. Historians have noted the irony that Queen Victoria herself did not personify the chaste stereotype.11 More nuanced histories have objected to this strict dichotomy between modest ‘good’ women and promiscuous ‘bad’ women, highlighting instead a range of beliefs, including those authorities who considered mutually agreeable sexual intercourse to be beneficial to health and conjugal contentment.12 While more work undoubtedly needs to be done on this, much evidence remains that female attempts to reject this ‘cult of domesticity’ were viewed with suspicion and hostility. The ‘two-sex’ model and ‘separate spheres’ concept gave tacit acceptance to men’s greater sexual needs. The belief that premarital or extramarital sex was excusable only in men was known as the ‘double standard’. While societal standards differed between cultures and classes, men fared much better than women with respect to sexual transgressions. The Napoleonic Code clearly established the husband’s supremacy, under which only adulterous wives could be prosecuted by the state. Although the prostitute embodied all that was pathological about active female sexuality, she was considered in some quarters a necessary evil to accommodate male ‘urges’. The double standard did not go unchallenged. With the actions of the prostitute’s (male) customers rarely considered or problematized, prostitution constituted a burning issue on the feminist agenda. Inequality related to class as well as gender, since working-class girls appeared to be ‘sacrificed’ for upper-class women to remain chaste. However, recent studies portray a varied range of male behaviours, with many men resisting prostitutes for moral, physical, or economic reasons.13 More research is required to establish the extent to which prostitutes were resorted to and who their customers were. What to do about prostitution became the subject of heated debate amongst politicians, reformers, and physicians. ‘Sexual pragmatists’ considered prostitution fatalistically as an inevitable or necessary societal institution that should simply be tolerated. Others attempted to ‘rescue’ prostitutes from their plight. Some virtuous citizens embarked upon private initiatives of lodging and befriending prostitutes. On a larger

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scale, institutions such as the Magdalene asylums were established to rehabilitate prostitutes through a combination of religious instruction, hard physical labour, strict discipline, and the inculcation of bourgeois standards. More broadly, the prostitute was redefined as a threat to public health. Much of Europe imitated France by establishing regulatory systems in order principally to control the spread of venereal disease by medically policing prostitutes. In parts of the United States, alternatively, a vigorously repressive approach that criminalized commercial sex was adopted. While some scholars busily endeavour to modify or overturn accepted Victorian sexual stereotypes, the English physician William Acton (1813–75) remains much cited as a classic example of Victorian prudery and hypocrisy. In statements such as ‘the majority of women (happily for them) are not very much troubled by sexual feelings of any kind’, he clearly articulated the double standard within a medical context.14 For Acton, decent women did not desire sexual gratification, but selflessly submitted to please their husbands. Though some have considered Acton’s asexual view of women peculiar to England, similar evidence has been found in other parts of Europe and North America at this time, including statements from the leading French authority, Alexandre Mayer. Moreover, Acton was challenged by many of his British contemporaries, so that his views should not be seen as entirely representative even locally. Some British doctors clearly recognized the importance of the clitoris and encouraged equal female participation in sexual relationships. In fairness, Acton’s comments on female sexuality were made merely in passing in a book on the male sexual organ. Indeed, in other areas of his work, scholars have characterized Acton as a ‘revolutionary innovator’.15 Though multiple and contradictory definitions of female sexuality can be discerned, to a pronounced extent female sexuality was not only pathologized but psychiatrized. Wilful rejections of the ‘angel in the home’ ideal were commonly linked to mental instability. Indeed insanity has historically been represented as the ‘female malady’.16 Where their female patients were concerned, nineteenth-century psychiatrists appeared to define their task as the maintenance of brain stability in the face of almost overwhelming physical odds. Such beliefs were epitomized by the psychiatric disease ‘hysteria’, named after the Greek word for uterus and associated with female sexual arousal. Psychiatric treatments of such female maladies tended to focus upon the regulation or extirpation of a woman’s libido. The most dramatic treatment in this regard was clitoridectomy, the surgical removal of the clitoris, a procedure performed during the midnineteenth century but quickly discontinued amid fierce opposition. Though its statistical incidence is likely to have been slight, much has been made of its symbolic importance, the surgical enforcement of an ideology that eliminates the woman’s sexual pleasure and restricts her sexuality purely to reproduction. Thousands of ovariotomies were also practised in America and Britain.17 Nor was the reproductive domain necessarily the safest place for women. Indeed, nineteenth-century psychiatrists linked female insanity to the biological ‘crises’ of the life cycle: puberty, pregnancy, childbirth, and menopause. The term ‘puerperal insanity’ encompassed that form of insanity that befell pregnant women and new mothers.18 This diagnostic label seemed to cover a miscellany of symptoms, from brief nervous upsets to

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violent mania. Nonetheless, it was seen as emblematic of women’s intrinsic biological weakness, fragile nervous system, and unpredictable reproductive organs. With motherhood central to Victorian femininity, an inability to adapt to its demands constituted an inability to perform a woman’s most important life functions. The ideological centrality of motherhood also problematized the status of contraception. While doctors played some part in issuing contraceptive devices such as diaphragms, the profession largely rejected involvement, branding family planning an ‘improper’ medical pursuit. This was partly an ethical concern, given the disreputable connotations of contraception at this time, particularly the condom, and vigorous objections to ‘artificial’ birth control from the Catholic Church. Doctors also complained that their professional status might be undermined, given its technologically unchallenging nature. Some even warned of the physiological dangers that contraceptives posed. Aside from the physician’s role, recent scholarship has criticized the limited extent to which male roles and attitudes have been considered. Women have been placed firmly at the centre, with female knowledge networks investigated rigorously, due in part to the rich source material but also to the (mis)apprehension that women played the central role. This gender imbalance is just beginning to be overturned, in the knowledge that men had greater access to sexual information and were more at ease in discussing it.19 Contraception was not always successful of course, resulting in unwanted pregnancies. Though by 1900 abortion was generally illegal except to save the mother’s life, prior to ‘quickening’ (feeling foetal movement in the womb) women often appeared to seek remedies to ‘bring on’ menstruation with few moral qualms. Contraception and early abortions were popularly linked on a fertility regulation continuum. Women’s sheer desperation as the pregnancy progressed was revealed by their seeking out often dangerous illegal abortions, purchasing the abortifacients advertised by quacks, or attempting to self-induce abortion. Some women died from infection or blood loss, others were rendered sterile; many were hospitalized and became the medical profession’s problem. Abortion was also riven with class bias. Where one could afford it, doctors could usually be found who would justify, albeit clandestinely, a ‘therapeutic’ termination. Abortion statistics are extremely difficult to reconstruct, given the furtive nature of the enterprise. Evidence is more plentiful for illegal abortions brought to trial, though the law differed from country to country; in England, for example, women did not need to be pregnant for prosecution to take place.20 However, women were generally treated as the abortionist’s victim, providing doctors with another reason to avoid involvement. The nineteenth-century marital and maternal frameworks within which female sexuality was contained continued into the twentieth century. However, the First World War exerted some impact, amidst growing employment and leisure opportunities and a decline in parental control. However, a declining birth rate, high infant mortality rate, and the loss of young, virile lives in battle fuelled ‘race suicide’ fears and pro-natalist state policies throughout Europe. Fertility concerns were accentuated by the increasing number of middle-class women pursuing a higher education, which critics claimed interfered with motherhood. These years also saw the rise of the ‘amateur’ prostitute, a term coined to encapsulate growing fears of women who engaged in pre-marital sexual

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activities without charging a fee. While such concerns suggest that virginity and fertility remained prized female assets, evidence of growing sexual experimentation has led some scholars to label these decades the ‘first sexual revolution’.21 Any evidence of ‘revolution’ must, nonetheless, be contrasted with evidence of sexual dissatisfaction at this time, not least the thousands of letters received by the English birth control pioneer, Marie Stopes (1880–1958). These letters reveal much interwar sexual dissatisfaction and ignorance, which encouraged Stopes and her American counterpart Margaret Sanger (1879–1966) to fight for birth control to be made available to the masses for the good of their health and happiness and for the good of the state in improving the quality of the race by lowering fertility in the poor and unfit. Both women published educational tracts on the subject—Sanger’s Family Limitation (1914) and Stopes’s Wise Parenthood (1918)—and concurrently established birth control clinics in their respective countries. Their passionate intention to unveil sexual ignorance contrasts starkly with the medical profession at this time, which considered the dissemination of such knowledge dangerous and polluting. However, historians have suggested that such dissemination actually bred sexual dissatisfaction because it led women to expect more than their Victorian ancestors, an expectation that was not met. Nonetheless, female sexual liberalization continued on both sides of the Atlantic, with rates of premarital sexual intercourse almost doubling during the interwar years. Sexual commentators such as Alfred Kinsey (1894–1956) attributed female sexual liberalization not only to the work of sexual modernists such as Stopes, but also to the ‘purity’ and feminist campaigns against prostitution, which encouraged men to seek sexual satisfaction within courtship and marriage.22

Male sexuality Acton’s views on male sexuality appeared more typical of the Victorian medical profession than his views on female sexuality. His writings evinced a clear tension between viewing the male sexual urge as a powerful and inevitable physiological process and one in need of self-control due to the potentially debilitating effects of seminal loss. For nineteenth-century doctors, the body constituted a fixed reservoir of sexual energies that, if wasted, could never be replenished. Sexual excess and masturbation drained these finite reserves, risking physical and mental decline. Though not nearly to the same extent as in females, such medical views problematized male sexuality as a threat to body and mind. A man was to be proud of his virility, but ideally to channel it into responsible marital relations. By the early twentieth century, sex writers were deploring the ignorance and selfishness of men in the marital bed and stressing mutual pleasure as the ultimate goal. While male sexuality was often depicted as rampantly lustful, male sexual anxiety and ‘wedding-night impotence’ appear to have been widespread. Physicians attempted to cajole men out of their sexual inhibitions and thoughtlessness by educating them on

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how to satisfy their conjugal partner. The Dutch gynaecologist Theodoor Hendrik Van de Velde’s (1873–1937) widely circulated Ideal Marriage: Its Physiology and Technique attempted to educate married couples in sexual anatomy and the cultivation of erotic technique. In the early eighteenth century, Western fears regarding the potentially deleterious effects of ‘self-abuse’ had emerged.23 This act became widely known as ‘onanism’, named after the biblical figure Onan, who ‘spilled his seed’ (coitus interruptus) to avoid impregnating his brother’s widow. Onan epitomized the Christian abhorrence to sexual intercourse for reasons other than procreation. Indeed, some churchmen viewed rape more preferably, given its greater likelihood to create offspring. Others considered masturbation the precursor to homosexual acts. Anti-masturbation literature flourished as the Victorian moral panic surrounding ‘solitary vice’ reached its climax. Physicians contributed significantly, warning of the dangers of ‘spermatorrhoea’, the morbid emission of semen, a vital fluid whose reckless expenditure could cause serious physical wasting and insanity. Nocturnal emissions were similarly pathologized. Anxious men rushed for drastic surgical and pharmacological remedies such as depressant drugs, the wearing of spiked collars to prevent unwanted erections, and circumcision. The double standard notwithstanding, it was not just female sexuality that suffered at the hands of doctors. However, the ultimate threat to the creation of offspring was homosexuality, a sexual preference regarded as a pathological process, a danger to the state, or both. Psychiatrists debated whether homosexuality was congenital or acquired and proposed ‘curative’ strategies, including aversion therapy, oestrogen treatment, and castration. In certain respects, the medicalization of homosexuality fostered greater police and judicial scrutiny and the reconceptualization of homosexuality from ‘sin’ to ‘crime’, ironically given that several prominent sexologists protested against homosexual laws. The English physician Havelock Ellis (1859–1939) challenged the British Labouchère amendment to the 1885 Criminal Law Amendment Act, which criminalized acts of ‘gross indecency’ between adult males, the law under which Irish playwright Oscar Wilde (1854–1900) was imprisoned. While the Austrian psychiatrist Richard von Krafft-Ebing’s (1840–1902) Psychopathia Sexualis is often considered the classic sexological example of the pathologization of homosexuality, he in fact supported the campaign against Paragraph 175 in Germany which punished ‘unnatural’ intercourse between men. It was in National Socialist Germany that homosexuals were probably most persecuted. The Nazis denounced homosexuality as a national threat that rendered men effeminate and impotent. Hitler’s regime strengthened Paragraph 175, sent police out to raid homosexual clubs, and ordered the forcible castration of men accused of sex crimes, which included homosexual acts. An estimated 10,000 homosexuals were sent to the concentration camps, where they were consigned to the bottom of the inmate hierarchy.24 The Nazis were only an extreme example. Authorities throughout Europe and North America exercised their legal apparatus amidst fears that male homosexuality would degenerate manhood. German anti-homosexual laws—in common with most European nations—were not extended to lesbians since these women could procreate.

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The Second World War was arguably a crucial turning point in increasing the visibility—and vulnerability—of urban-dwelling gays to police and medical surveillance, including the McCarthyist attempts to prevent homosexuals from infiltrating positions of power. This new visibility also united efforts to pressure governments into reforming homosexual laws. Although the British Wolfenden Committee (1954–7) recommended the decriminalization of homosexual behaviour between consenting adults, its proceedings were conducted within a regulatory medical framework that continued to pathologize gay men, heavily influenced by psychiatric interpretations of homosexuality. Indeed, attempts to ‘treat’ homosexual men reached a peak in 1970s Britain, despite the 1967 Sexual Offences Act decriminalizing homosexual activities in private for adults in England and Wales. It was not until 1973 that the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s widely read handbook, notoriously dropped ‘homosexuality’ as a diagnostic category, and even then to fierce opposition by some psychiatrists. Within Europe, the more widely used International Statistical Classification of Diseases did not omit ‘homosexuality’ until 1993. Indeed, a 2009 study found that a ‘significant minority’ of British mental health professionals continued to offer treatments to change a client’s sexual orientation from homosexual to heterosexual, despite the possible harmful effects and distinct lack of evidence for the efficacy of such therapies.25

Venereal disease Social and political concerns surrounding sexually transmitted diseases have been seen to both reflect and reinforce society’s most fundamental assumptions and fears surrounding sexuality and disease. Earlier histories debated vigorously the origins of these diseases, particularly syphilis. Had it been present from prehistoric times, as suggested by Hippocrates having described such symptoms in Classical Greece, possible biblical references, and more recent skeletal analysis? Or, in light of the sudden arrival of a devastating syphilis epidemic that swept Western Europe during the later fifteenth century, was it a New World disease brought by Columbus’s discovery of the Americas? The epidemic’s intensity caused considerable fear and speculation among physicians and lay people alike as to its origins. With no conclusive evidence but widespread recognition of the pain, deformity, and death that accompanied it, each nation was keen to attribute blame to others. Thus it was the ‘Italian disease’ to the French and the ‘French disease’ to the Italians, with no nation wishing to claim it as their own. However, by the early nineteenth century, venereal disease was no longer characterized predominantly as a xenophobia-driven disease. A new vector had replaced foreigners: women. As incidence increased markedly, prostitutes—an obvious symbol of sexual excess and deviancy—became the focus of moral and public health concern. The medical profession made explicit links between prostitutes and venereal disease, and argued for the physician to take a leading role in the control of both. As one Scottish

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surgeon wrote: ‘The medical man must be conjoined with the policeman in this dirty and degrading work. With speculum in hand he must go from brothel to brothel.’26 With increasing diagnostic confidence, physicians searched for signs of venereal disease, but also for physical defects more generally, the ‘stigmata’ of their transgressions that distinguished prostitutes from ‘normal’ women. By the later nineteenth century, the anthropologically minded were portraying such physical anomalies as signs of atavism characteristic of a more primitive evolutionary stage. Feminists attempted to shift the blame for racial deterioration to men and to characterize venereal disease as the consequence of male sexual hypocrisy rather than female promiscuity. Social purity activitists branded the double standard and commercial sex as the chief contaminants of domesticity, with the prostitute’s clients polluting the home. Nonetheless, the focus remained predominantly on women, even in the domestic environment where the ‘innocent’ wife of a profligate husband might spread congenital defects to her children. Difficulties in how to define the ‘prostitute’ only served to legitimate the control of greater numbers of women. By the early twentieth century, the ‘amateur’ prostitute was cast as the new reservoir of venereal disease. She came from all social classes, tended to be younger, and, most worrying of all, had no commercial motivation. By the mid-twentieth century, the ‘amateur’ had become the ‘easy’ girl. Coercive strategies continued to be employed to treat and reform these ‘problem’ girls. Networks of clinics offered punitive treatments such as urethral irrigation long after doubts had emerged over their effectiveness. Medical belief and behaviour remained bound by powerful social and moral codes. Warfare had a particularly powerful impact upon the surveillance and regulation of female sexual behaviour, given the perceived relationship between venereal disease and prostitution, the frequency with which soldiers and prostitutes were believed to consort, and the necessity for those defending the nation to be physically fit. Inspired by European regulationist systems, and justified by the medico-military establishment, English concerns over the high level of venereal disease diagnosed (accurately or otherwise) in Her Majesty’s armed forces led to the introduction of the infamous Contagious Diseases Acts during the 1860s, under which prostitutes in designated port and garrison towns could be compelled to submit to medical examination. If found to be venereally infected, these women were to be imprisoned until treated and cured. These Acts, discussed extensively by historians, served as a model for other nations and enshrined in law the belief that the body of the prostitute was inherently diseased.27 Although the application of these Acts was by no means universal across Britain and its colonies, they precipitated extensive debate. Some factions welcomed them and even argued for their extension to protect the civilian population. Others objected vociferously, particularly feminists who felt that the Acts degraded womankind while treating men with impunity. Josephine Butler (1828–1906) toured England protesting against women’s ‘surgical rape’ by police surgeons and demanding a single moral standard. Civil libertarians objected to the brutal examination and incarceration of women without trial. Some physicians questioned attempts to tackle an infectious disease by treating only half the population. Such objections fed into the rise of an international abolitionist

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movement that opposed state regulation of prostitution. By the 1880s, the campaign to repeal the Acts had developed into a mass movement and they were repealed in 1886. However, deep concern over the polluting potential of female sexuality upon male troops remained. During the First World War, informed by national efficiency concerns, complaints that ‘diseased women’ lay ‘in wait for clean young men who came to give their lives for their country’ were voiced.28 The 1918 British Defence of the Realm Act (DORA) subjected women to another dose of oppressive regulation by stipulating that no woman suffering from venereal disease was to have sexual intercourse with any member of the armed forces. A woman so charged was to be remanded for medical examination. In once more penalizing women for the sexual behaviour of men, this effective return to the Contagious Diseases Acts was subjected to similarly widespread protests. With six million newly enfranchised female votes now at stake, DORA 40d was revoked as the war ended. The medical specialty of venereology, later rebranded ‘genito-urinary medicine’, was consistently low in status. Sufferers were also excluded from many hospitals, with doctors seemingly reluctant to deal with the ‘wages of sin’. Moreover, many men preferred to consult quacks who promised quick and discreet treatments for this and for male sexual anxieties such as impotence. The mass distribution of penicillin during the 1940s finally appeared to signal the end for venereal disease. However, within just a few decades such infections had paled into insignificance as a new disease cast an apocalyptic shadow over sexuality. By 1988, acquired immune deficiency syndrome (AIDS) had been reported in 138 countries and was estimated to have infected 10 million individuals.29 It was soon established that AIDS spread as a result of the human immunodeficiency virus (HIV). Contracted through sexual contact or infected blood, the disease crippled the body’s immune system, causing severe morbidity and high mortality. A number of historical parallels can be drawn between AIDS and venereal disease: the primacy of establishing the disease’s origins and its principal vectors; the moralistic separation of ‘innocent’ from ‘guilty’ victims; and the fundamental conflict between individual liberty and communal good revealed in official responses to the diseases. It was deemed crucial from the outset to pinpoint those responsible for this sexual Armageddon. Allegations that AIDS had started in the ‘dark continent’ of Africa allowed the resurrection of ‘primitive’ and ‘licentious’ racial stereotypes, though others counterargued that the killer virus was a form of germ warfare, an American attempt to decrease the spiralling African birth rate. Xenophobic propaganda attempted to stigmatize the sexuality of other races. Some Germans called for foreigners to be automatically screened for AIDS, while the French National Front used the disease to campaign for immigration restrictions. In addition to black immigrants, women were considered potential threats to health, particularly prostitutes, for the threat they represented to white men, and black women were reproached as the irresponsible mothers of AIDS babies. However, in contrast to venereal disease a century earlier, neither group was depicted as the principal vector. Scientists initially labelled the disease ‘gay related immune deficiency’ (translated in the press as ‘gay plague’), and suggested that a gay lifestyle had overloaded the body’s

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immune system, with AIDS a physiological protest against unnatural sexual activity. Such pronouncements resurrected fear and resentment towards a community that had only recently achieved a visible element of liberation. The appearance of the virus in another deviant minority—injecting drug users—provided further reassurance that the majority of the population were not at risk and further opportunities to view AIDS metaphorically as nature’s vengeance upon a society unwilling to live by God’s rules. Contemporaries framed a picture of AIDS that sought to reduce the threat that the randomness of disease posed to them while simultaneously articulating their own cultural values.30 The siphoning of AIDS into these particular bodies appeared to justify a ‘business as usual’ policy for heterosexuals and laissez-faire governments on both sides of the Atlantic. By the later 1980s, the realization of white heterosexual risk sparked significant state, scientific, and public-health involvement in detection, management, education, and prevention. Nonetheless, AIDS continued to provide conservatives with a justification to ostracize marginal groups. The language of guilt and innocence was revised, with sympathy reserved for ‘victims’ whose race and sexual orientation had not contributed to their illness. While anti-retroviral drugs have begun to achieve success in slowing down the infection’s progress, figures remain alarming. By 2008, World Health Organization figures showed that 33 million people were living with HIV/AIDS worldwide and that 2 million people had died from the disease in that year alone.31

The science of sexuality From the mid-nineteenth century, concerted efforts were made to subject sexual variation to scientific scrutiny. These ‘sexologists’ attempted to label and classify sexual ‘types’; terms such as ‘homosexuality’ and ‘sadism’ entered scientific discourse. Variations from the perceived norm quickly became the focus of attention as Victorian sexual science appeared to set about pathologizing ‘deviance’ and policing the boundaries of respectability. Historians have noted the medicalizing tendencies of sexology: its attempt, consciously or otherwise, to supplant older moral categories of ‘sin’ and ‘excess’ with more medical or psychological categories such as ‘degeneracy’, ‘disease’, and ‘insanity’, and to establish underlying aetiologies. Perversions became a matter of hereditary predisposition and biological or psychological defect rather than moral flaw, matters requiring an enlargement of the doctor’s remit. What motivated the sexologists’ endeavours has been debated enthusiastically. Interpretations range from sexual scientists as agents of enlightenment and even emancipation through to executors of repression. They did not, of course, speak with one voice and their findings could be employed to both erode and reinforce traditional sexual boundaries. What is clear is that the sexologists were not, as some stated themselves to be, simply investigating sexuality as factual and neutral observers. They were proscribing as well as describing.

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The roots of sexology lay partly in Victorian England with William Acton, whose 1857 publication The Functions and Disorders of the Reproductive Organs remained a standard authority until the early twentieth century, albeit partly due to lack of competition. He was succeeded by Havelock Ellis, a physician whose scholarly writings were published in expensive limited editions that ensured they reached ‘appropriate’ hands. Such ‘respectability’ was contrasted with the output of ‘foreigners’ such as the Austrian psychiatrist Richard von Krafft-Ebing. While occasionally dressed honourably in Latin, his encyclopaedic Psychopathia Sexualis (1886) coined and classified a smorgasbord of sexual transgressions from adultery to zooerasty, a trend continued by Ellis’s Studies in the Psychology of Sex (1897–28). Crucially, Ellis located ‘transgressive’ types at the extremes of a normal continuum of sexual behaviour, thus characterizing sadism as merely an exaggerated form of male aggression and transvestism as an excessive demonstration of heterosexual love for the female. His focus upon ‘normal’ sexual behaviour was, as he himself implied, no more than what society defined to be normal. By the mid-twentieth century the sexological epicentre had shifted to America, principally through the work of the biologist Alfred Kinsey and the more practice-oriented ‘sex therapists’ William Masters (1915–2001) and Virginia Johnson (1925–). Kinsey’s surveys of male and female sexuality were published in 1948 and 1953, respectively. The ‘Kinsey reports’ appeared to uncover far greater levels of same-sex attraction and sexual activity than previously imagined, to the horror of those attempting to redress the Second World War’s perceived corrosive impact upon gender norms and family stability.32 Castigated by conservative moralists as an academic voyeur, his explosive findings nonetheless had a profound impact upon Western social values. The chasm between God-fearing ideals and actual sexual behaviour appeared wider than ever feared. Yet, crucially, Kinsey took great care to portray the fluidity of sexual desire rather than to use loaded terms such as ‘frigid’ and ‘over-sexed’ or to adopt narrow stereotypical categories such as ‘heterosexual’ and ‘homosexual’, too often translated into ‘normal’ and ‘abnormal’. In the main, an idiosyncratic transnational group of individuals were drawn to sexology. A tormented youth filled with guilt over sexual impulses he did not understand, followed by his marriage to a lesbian, apparently attracted Ellis to sexology. The married gynaecologist Van de Velde entered the speciality after his elopement with a married patient, a scandal that forced him to leave the Netherlands. The botanist and ‘agony aunt’ Marie Stopes claimed that her own sexual ignorance—she allegedly took over a year to realize that her marriage had not been consummated—propelled her to write her first book, Married Love (1918), and to dedicate her life to improving marital happiness. It has, however, been questioned whether Stopes was quite as sexually naïve as she portrayed herself to be, with hints of same-sex attraction before that marriage and a possibly ‘open’ second marriage. A fabricated veil of naïvety might have helped shield her feminine modesty, as would the sexologists’ cultivation of legitimating scientific credentials. Ellis tactically completed medical school to give his writings authority rather than

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to practice medicine. Half a century later, William Masters was advised to establish a reputation as a scientist in another field before embarking upon the study of human sexuality. This preliminary step is perhaps ironic since the sexologists were never truly accepted into mainstream science. The sexologist’s fate was often an unenviable combination of professional isolation, public notoriety, and even prosecution. In 1899, Ellis advised his colleagues to be content if they met ‘with nothing worse than indifference’.33 The previous year, the first volume of his Studies in the Psychology of Sex had been prosecuted for obscenity, with not a single doctor joining the campaign for the book’s defence despite acknowledgement of its medical credentials. Half a century later, Kinsey’s Rockefeller Foundation funding was terminated as a result of public furore, establishment outrage, and Cold War paranoia. Explicitly medical involvement in the creation of the discipline of sexology and the dissemination of its findings was ambiguous to say the least. While medical understandings of the human body became increasingly sophisticated, the sexual organs were largely ignored. Sexuality featured only vaguely in medical curricula. In Britain, venereology was not taught until the 1920s, nor family planning until the later 1930s. These fields were among the lowest in status. Sexual research became increasingly divorced from the living body as scientific advances were made in, for example, biochemical analysis. Furthermore, most clinicians were agreed that, while they required some working knowledge of sexual anatomy and behaviour, their findings must not be disseminated to the lay public. As the British Medical Journal noted in relation to Krafft-Ebing’s work: ‘There are many morally disgusting subjects which have to be studied by the doctor . . . but the less such subjects are brought before the public the better’.34 Despite such reluctance to share sexual knowledge with the public, one can discern various linkages between sexology and sex education. From at least the Enlightenment, and especially from the late nineteenth century through compulsory schooling and the publication of numerous pedagogical texts, sex education constituted part of the process by which children were guided into adulthood. Both endeavours can be seen as an attempt to regulate sexual activity and to construct sexual norms. Both were also perceived to be highly contentious. Sex education policy-making has represented an area of enduring conflict between the competing ideologies of state, teacher, and parent. Despite the widespread feeling that responsibility to provide sex education lay in the home, evidenced for example by the 1940s Mass Observation ‘Little Kinsey’ sex survey,35 many parents were—and remain—unwilling to provide their offspring with the ‘facts of life’, a reluctance often welcomed by the child. Sex education tended to be marginalized within the school curriculum. Thus, throughout Europe and North America, other agencies stepped, or were cajoled, into the breach: the medical profession, churches, and voluntary organizations such as purity activists. However, further conflict ensued as to the appropriate distribution of responsibility. Moreover, content remained controversial, providing a focus for wider social anxieties over sexuality and childhood. A society that feared the corrosive effects of perusal of Krafft-Ebing and Kinsey feared the potentially detrimental effects of sexual knowledge, particularly sexual precocity. Not all sexual knowledge was considered benign,

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particularly that derived from sources perceived to be commercial or ‘vulgar’, which might instead encourage licentiousness and corrupt youthful innocence. Mere awareness of immodesty or sexual disease might contaminate. Although doctors accepted an increasing role in the delivery of sex education over the twentieth century, biological content and ‘scientific facts’ might still be sacrificed in favour of a strategy intended simply to instil fear. By the late twentieth century, the dominant discourse remained one of risk, not pleasure. The ‘mechanics’ of sexual behaviour were generally avoided in favour of the problems associated with the sexualization of youths, including sexually transmitted disease, teenage pregnancy, and damage to moral character. Feminist historians have also highlighted the gendered nature of sexual pedagogy; its segregated delivery and content have strengthened the ideological process that ‘locks women into their maternal and familial roles’.36 Given such shortcomings in officially sanctioned sex education, the historiography is beginning to consider less ‘official’ means through which sexual knowledge was transmitted, though this is a particularly problematic history to access. Magazines, pornography, television programmes, peer-group interactions (information acquired ‘behind the bike sheds’), and, more recently, the internet are likely to have shaped sexual knowledge. Questions remain as to the processes by which youths acquired knowledge, what they actually knew, and how knowledge influenced behaviour. Even the specific content of school-based sex education, let alone crude playground exchanges, is a mystery in many regions. There remains much to explore, if the source material can be found.

The permissive society One of the most popular cultural stereotypes of the twentieth century is that the 1960s witnessed a ‘sexual revolution’, an orgy of permissiveness revolving around sex, drugs, and rock and roll, but mostly sex. The mass media depicted in increasingly graphic detail a world of nudity and free love. Much of the new permissive society revolved around women. Bras were burnt and hemlines crept shorter as female sexuality was released from suffocating male-defined Victorian boundaries. Sexual surveys revealed a dramatic transformation in public attitudes and in sexual behaviour itself, or perhaps rather they revealed that there were decided discrepancies between conventional morality and private behaviour. Such behaviour may have stemmed from several sources. The publicity surrounding sexological studies perhaps encouraged experimentation, or reassured ‘transgressors’ that they were in good company. Sexual reform movements began to have an impact on social life. A number of countries relaxed their restrictive legislation, including that governing homosexuality and abortion, as governments felt pressurized into acknowledging changing lifestyles and tolerances. Medical developments played a vital part. The successful treatment of venereal diseases with antibiotics facilitated a more promiscuous lifestyle. Crucially, the oral

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contraceptive pill divorced penetrative sex from reproduction and undermined the need for virginity until marriage. There has been strong disagreement amongst scholars as to whether this development actually emancipated women, with negative assessments suggesting that they no longer had an excuse to say ‘no’ and were simply made more available to men through contraceptive technology. Nonetheless, the pill was clearly central to any revolution in sexual behaviour. While women were quick to accept the pill when it came onto the market from 1960, many doctors were initially morally opposed to prescribing oral contraception. Historians have attributed the pill with breaking down medical reluctance on both sides of the Atlantic and in ‘medicalizing’ contraception.37 The pill undoubtedly placed contraception on a more scientific level, available only on prescription since specific hormonal dosages were required to be measured. The regular check-ups that the pill was seen to necessitate have been interpreted by some as responsible preventive medicine and by others as a cynical way for physicians to unnecessarily scrutinize the perfectly ‘healthy’ female reproductive body. Another significant reproductive health development was the liberalization of Western abortion laws. The British Abortion Act (1967) helped spark this trend, making termination legal where the risks to a pregnant woman, or her existing children, were greater than the risks from abortion. However, two doctors were required to certify that appropriate indications existed, the Act thus falling short of women’s organizations’ wish to let women decide for themselves. Many obstetricians and midwives initially resented this new responsibility, both because of the pressure it placed on gynaecological resources and because they considered abortion the antithesis of their responsibility to bring life into the world, but doctors quickly came to accept control in the abortion decision-making process. The absence of a woman’s ‘right to choose’ in early pregnancy differentiated Britain from many countries’ abortion legislation, including the United States (1973). Feminist analysis has been highly critical of British abortion provision leaving women dependent on medical discretion, though acknowledging that this has depoliticized abortion, in stark contrast to American militant ‘pro-lifers’.38 Any discussion of a ‘sexual revolution’ must be embedded within a wider political context, with the liberation of sexual behaviour linked to campaigns for citizenship and social justice. There were also important social and demographic transformations that permissiveness tapped into. During the 1960s and 1970s, the average age at marriage began to rise, the divorce rate increased, and the birth rate began to decline after the ‘baby boom’, the phenomenon of increased births charted in Europe, North America, and Australasia in the years immediately after the Second World War. Men and women spending a larger part of their lives as ‘singles’ meant a large market of sexually available people. Some historians question the suitability of the term ‘revolution’, suggesting that it either exaggerates the profundity of transformations or gives a misleading impression of straightforward liberation, where in fact these decades signalled the emergence of a variety of competing sexual agendas. Other scholars question the exact chronology of sexual change.39 To a lesser extent, scholarly criticism has focused upon geographical

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variability. Different nations found themselves at different stages of sexual change, many in the shadow of Britain and the United States. Abortion remains illegal in much of Central and South America, the contraceptive pill was only introduced to Russia in the late 1980s, and in India homosexuality was not decriminalized until 2009. Even in America and Britain, regional studies are beginning to reveal that the timing of sexual change varied considerably between areas.40 With the 1960s and 1970s widely caricatured as a time of sexual liberation, the 1980s and 1990s have tended to be characterized as a period of backlash and retribution. This was due largely to the appearance of the deadly disease AIDS, which significantly intensified existing fears over sexuality, both real and imagined. The price of permissiveness was also seen in rising rates of sexually transmitted diseases, teenage pregnancy, and divorce. Conservatives used such widespread evidence of ‘moral decay’ to urge a return to wholesome moral values and greater policing of sexual deviancy. However, movements for a new sexual conservatism have met with only very limited success so far, with indicators of continued liberalization all around us in the West. Sex, both heterosexual and homosexual, has become more visible and explicit. Lifestyles previously considered unacceptable have become increasingly commonplace. Whether or not people are engaging in sexual activity more frequently, sexual intercourse arguably began to carry much less significance once detached from the lifelong commitments of marriage and procreation.41 The family is arguably a more fluid grouping, no longer defined by marriage, heterosexual parenting, and legitimate births. Social commentators continue to debate the extent to which such changes are signs of progress or depravity.

Conclusion The sexual sciences, while noticeably ‘medicalized’ over the past century, continue to straddle an uneasy ground between legitimate research and titillation. Suspicions linger that professional respectability is somewhat tainted by involvement in sexual matters, while the public question medical motivations to pathologize and ‘treat’ sexuality. Though many doctors now accept their gatekeeping role in reproductive health, some continue to question being asked to make complex non-medical decisions with only their own principles to guide them, a sense of discomfort echoed by voluntary organizations. Much still depends upon the social milieu in which medical advice is sought, with the continued conflation of medical and moral discourses surrounding sexuality. Abortion and infertility services remain a ‘postcode lottery’ of geographic variability, while services such as cervical screening and contraception are often farmed out to specialized clinics and voluntary bodies, supported by many women who choose such clinics over their family doctor. A consensus over the content and delivery of sex education continues to be elusive, as does a solution for the perceived ‘epidemics’ of teenage pregnancy, abortion, and sexually transmitted infections. Medical and lay perceptions continue to conflate sexuality with danger and pollution, and to associate risky or

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deviant behaviour with particular bodies, demonstrating powerful misogynistic, homophobic, and xenophobic tendencies. While we have escaped the reign of Victorian euphemism—the venereal ‘social diseases’, the ‘social evil’ of prostitution, and the ‘solitary vice’ of masturbation—inhibition and ignorance remain, and ironically so considering the omnipresence of sexual imagery and language in popular culture. However, great emancipatory strides have undoubtedly been made, due largely to the courage and tenacity of voluntary bodies and to a lesser extent through medical and scientific contributions. The activities and status of some of those voluntary bodies were, it should be noted, boosted considerably by the medical figures in their membership. While the history of sexuality is now thriving, early scholarly obsessions with deviance and marginality are only beginning to be displaced, allowing long overdue consideration of more ‘mainstream’ attitudes and behaviours. Fixations on female sexuality are being supplemented by historical insights into heterosexual masculinity, with the realization that women are not the only gendered subjects.42 More needs to be said on actual sexual practice, as opposed to ideologies, policies, and representations. An earlier focus on middle-class sexuality needs to shift towards the working classes, as appropriate sources that might reveal a very different story in relation particularly to Victorianism and the sexual revolution(s) are unearthed. Oral testimony may prove particularly valuable in opening up new avenues or challenging existing accounts,43 not least at a time when data protection and Freedom of Information legislation is causing the contemporary historian serious difficulties in accessing sensitive archival material. Geographically, we may see further detailed and contextual micro-histories of sexuality that will both furnish us with welcome new insights and bolster ambitious attempts to provide more comparative histories. Both approaches are a welcome departure from the skewed preponderance of metropolitan studies. Such innovative new research might provide a more symbiotic relationship between hard-line theoretical and empiricist approaches. Historians of sexuality should also consider the ways in which their research insights can assist policy-makers in formulating current sexual health policies.44 Given the wide range of social, cultural, and political issues that historians explore through the prism of sexuality, the questions they seek to answer are arguably of increasing relevance to modern Western society.

Notes 1. Vern Bullough, ‘Sex in History: A Virgin Field’, Journal of Sex Research, 8 (2) (1972), 101–16. 2. Keith Thomas, ‘The Double Standard’, Journal of the History of Ideas, 20 (2) (1959), 195–216. 3. Steven Marcus, The Other Victorians: A Study of Sexuality and Pornography in MidNineteenth-Century England (London: Basic Books, 1966). 4. Michel Foucault, La volonté de savoir (1976), translated as The History of Sexuality, vol. 1 (London, 1978). 5. Michel Foucault, Discipline and Punish: The Birth of the Prison (London, 1977). 6. Gerald McKenny, To Relieve the Human Condition: Bioethics, Technology, and the Body (Albany: State University of New York Press, 1997), 205.

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7. Lesley Hall, ‘Sexuality’, in Chris Williams (ed.), A Companion to Nineteenth-Century Britain (Oxford: Wiley-Blackwell, 2004), 432. 8. Hera Cook, The Long Sexual Revolution: English Women, Sex, and Contraception 1800–1975 (Oxford: Oxford University Press, 2004). 9. Thomas Laqueur, Making Sex: Body and Gender from the Greeks to Freud (Cambridge, MA/London: Harvard University Press, 1990). 10. Helen King, Midwifery, Obstetrics and the Rise of Gynaecology (Aldershot: Ashgate, 2007). 11. Hall, ‘Sexuality’, 431. 12. Lesley Hall, ‘The Sexual Body’, in Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (London/New York: Harwood Academic, 2003), 261–75. 13. Hall, ‘Sexuality’. 14. William Acton, The Functions and Disorders of the Reproductive Organ, 3rd edn (London, 1861), 101. 15. Lesley Hall, ‘ “The English Have Hot-Water Bottles”: The Morganatic Marriage between Sexology and Medicine in Britain since William Acton’, in Roy Porter and Mikulas Teich (eds), Sexual Knowledge, Sexual Science: The History of Attitudes to Sexuality (Cambridge: Cambridge University Press, 1994), 350–66. 16. Elaine Showalter, The Female Malady: Women, Madness and English Culture, 1830–1980 (London: Virago Press, 1987); Jonathan Andrews and Anne Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam/New York: Rodopi, 2004). 17. Jeffrey Weeks, Sex, Politics and Society: The Regulation of Sexuality since 1800 (London: Longman, 1989), 43. 18. Hilary Marland, Dangerous Motherhood: Insanity and Childbirth in Victorian Britain (Basingstike: Palgrave Macmillan, 2004). 19. Kate Fisher, Birth Control, Sex and Marriage in Britain, 1918–1960 (Oxford/New York: Oxford University Press, 2006). 20. Gayle Davis and Roger Davidson, ‘ “A Fifth Freedom” or “Hideous Atheistic Expediency”? The Medical Community and Abortion Law Reform in Scotland, c.1960–1975’, Medical History, 50 (1) (2006), 29–48, 31. 21. Stephen Garton, Histories of Sexuality: Antiquity to Sexual Revolution (London: Equinox, 2004), 210–14; Kevin White, The First Sexual Revolution: The Emergence of Male Heterosexuality in Modern America (New York: New York University Press, 1992). 22. Garton, Histories of Sexuality, 212. 23. Thomas Laqueur, Solitary Sex: A Cultural History of Masturbation (New York: Zone Books, 2003). 24. Angus McLaren, Twentieth Century Sexuality: A History (Oxford: Wiley-Blackwell, 1999), 138. 25. Annie Bartlett et al., ‘The Response of Mental Health Professionals to Clients Seeking Help to Change or Redirect Same-Sex Sexual Orientation’, BMC Psychiatry, 9 (11) (2009), http://www.biomedcentral.com/1471–244X/9/11, accessed 3 August 2010. 26. Cited in Linda Mahood, ‘The Wages of Sin: Women, Work and Sexuality in the Nineteenth Century’, in Eleanor Gordon and Esther Breitenbach (eds), The World is Ill-Divided: Women’s Work in Scotland in the Nineteenth and Early Twentieth Centuries (Edinburgh: Edinburgh University Press, 1990), 30. 27. Lucy Bland and Frank Mort, ‘Look Out for the “Good Time” Girl: Dangerous Sexualities as a Threat to National Health’, in Formations of Nation and People (London: Routledge and

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28.

29.

30. 31. 32.

33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

43. 44.

gayle davis Kegan Paul, 1984), 131–51; Mary Spongberg, Feminizing Venereal Disease: The Body of the Prostitute in Nineteenth-Century Medical Discourse (London: Palgrave Macmillan, 1997). Lucy Bland, ‘In the Name of Protection: The Policing of Women in the First World War’, in Julia Brophy and Carol Smart (eds), Women in Law: Explorations in Law, Family and Sexuality (London: Routledge, 1985), 47. Allan Brandt, ‘Sexually Transmitted Diseases’, in W. F. Bynum and Roy Porter (eds), Companion Encyclopedia of the History of Medicine, vol. 1 (London/New York: Routledge, 1993), 576. Charles Rosenberg and Janet Golden (eds), Framing Disease: Studies in Cultural History (New Brunswick, NJ: Rutgers University Press, 1992), Introduction. World Health Organization, http://www.who.int/hiv/en/, accessed 3 August 2010. Alfred Kinsey’s Sexual Behavior in the Human Male (1948) claimed that 37 of males surveyed had climaxed with another male. His Sexual Behavior in the Human Female (1953) affirmed that 30 of his female sample had made sexual contact with another female. Havelock Ellis, Studies in the Psychology of Sex, vol. I (New York, 1937), xxiv–v. Cited in McLaren, Twentieth Century Sexuality, 108. Liz Stanley, Sex Surveyed, 1949–94: From Mass-Observation’s ‘Little Kinsey’ to the National Survey and the Hite Reports (London: Taylor and Francis, 1995). AnnMarie Wolpe, ‘Sex in Schools: Back to the Future’, Feminist Review, 27 (1987), 37–47, at 38. Lara Marks, Sexual Chemistry: A History of the Contraceptive Pill (New Haven, CT/ London: Yale University Press, 2001), 116–37. Sally Sheldon, Beyond Control: Medical Power and Abortion Law (London: Pluto Press, 1997), 168. Garton, Histories of Sexuality, 210–28; David Allyn, Make Love Not War—The Sexual Revolution: An Unfettered History (New York: Little, Brown, 2000). Beth Bailey, Sex in the Heartland (Cambridge, MA/London: Harvard University Press, 1999). Cook, The Long Sexual Revolution, 339. Michael Roper and John Tosh (eds), Manful Assertions: Masculinities in Britain since 1800 (London: Routledge, 1991); Lesley A. Hall, Hidden Anxieties: Male Sexuality, 1900–1950 (Cambridge: Polity Press, 1991). Fisher, Birth Control, Sex and Marriage. Virginia Berridge and Philip Strong (eds), AIDS and Contemporary History (Cambridge: Cambridge University Press, 1993), Introduction; Simon Szreter, ‘History, Policy and the Social History of Medicine’, Social History of Medicine, 22 (2) (2009), 235–44.

Select Bibliography Clark, Anna, Desire: A History of European Sexuality (New York/London: Routledge, 2008). Davidson, Roger, and Lesley Hall (eds), Sex, Sin and Suffering: Venereal Disease and European Society since 1870 (London/New York: Routledge, 2001). Foucault, Michel, The History of Sexuality: An Introduction, trans. Robert Hurley (London: Penguin, 1990). Garton, Stephen, Histories of Sexuality: Antiquity to Sexual Revolution (London: Equinox, 2004).

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Hall, Lesley, Sex, Gender and Social Change in Britain since 1880 (Basingstoke: Palgrave Macmillan, 2000). Houlbrook, Matt, and H. G. Cocks (eds), Palgrave Advances in the Modern History of Sexuality (Basingstoke: Palgrave Macmillan, 2005). Laqueur, Thomas, Making Sex: Body and Gender from the Greeks to Freud (Cambridge, MA/London: Harvard University Press, 1990). McLaren, Angus, Twentieth Century Sexuality: A History (Oxford: Wiley-Blackwell, 1999). Nye, Robert (ed.), Sexuality (Oxford: Oxford Paperbacks, 1999). Sauerteig, Lutz, and Roger Davidson (eds), Shaping Sexual Knowledge: A Cultural History of Sex Education in Twentieth Century Europe (London/New York: Routledge, 2009). Weeks, Jeffrey, Sex, Politics and Society: The Regulation of Sexuality since 1800, 2nd edn (London: Longman, 1989).

chapter 29

medicin e a nd the mind r hodri h ayward

The mind and the mind sciences occupy an uneasy position in modern medicine. The sciences of psychiatry, clinical psychology, and psychotherapy dominate modern culture yet are vilified by critics both for their lack of internal consensus and for the ideological work they seem to perform. Although we use psychological vocabularies to explore, manage, and express the most intimate aspects of our identities, the theories and practices developed in these specialisms are (all too often) dismissed as rationalizations of political, economic, or gender interests. The ambivalent status of the mind sciences is reflected in contemporary medical practice. In clinical work, psychological phenomena are used to define the limits of medical knowledge. The attribution of cures to placebo effects marks the limits of a drug’s therapeutic efficacy, while the specious diagnosis of ‘all in the mind’ is still deployed to exclude patients from systems of medical treatment and care. The ambiguity inherent in the mind sciences stems from the instability of their fundamental concepts. The mind has no fixed qualities or capacities; rather it has been defined, from the seventeenth century onwards, through its assumed opposition to matter. This Cartesian definition has resulted in a concept of mind that resists scientific representation. When natural philosophers began to describe a mechanistic universe during the scientific revolution, the mind became ‘loaded’, as the philosopher E. A. Burtt (1892– 1989) noted, ‘with everything refractory to exact mathematical handling’. It became ‘a convenient receptacle for the refuse, the chips and whittlings of science.’1 The mind inherited all those appetites and qualities that had once animated the Aristotelian universe. The modern problem of mind and its relationship to matter cannot be solved through logical or epistemological reflection. It is a problem that can only be clarified though historical investigation since it rests upon contingent decisions made in seventeenth-century debates.2 Although commentators agreed that the mind possesses certain properties and capacities—passions, emotions, appetites, and intelligence—these properties cannot be known directly. Instead they are approached through surrogates. Changes in behaviour, verbal confessions, Rorschach test results, and digital reconstructions of

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cerebral activity are among the many signs used to indicate the presence of mental phenomena. Of course, this reliance on the use of surrogates is not unique to the mind sciences. Clinicians and pathologists might adduce the presence of the syphilis spirochete (Treponema pallidum) through the production of skin lesions or a positive reaction in a Wassermann test. However, whereas the spirochete enjoys some kind of existence beyond the lesion or the Wassermann reaction, ‘psychological objects’ are contingent upon, and completely bound up with, the metaphors and techniques we use to approach them. This idea that the psy-sciences do not simply describe their objects of investigation but also create them is based on the distinction in analytic philosophy between ‘natural’ and ‘human kinds’. Whereas natural kinds (such as the spirochete) maintain consistent characteristics and are indifferent to the ways in which they are classified, human kinds derive their specific features and properties—and indeed their very existence—from our acts of description.3 Some see psychological categories and classifications as good examples of human kinds. Labelling someone as a kleptomaniac, for instance, does not simply change the way we regard their behaviour; it also changes the way they understand their own motivations and the ways that they behave. It initiates what the philosopher Ian Hacking has termed a ‘looping effect’—an ongoing process of feedback between language, practice, category, and person.4 The extent to which psychological categories are simply human kinds remains open to debate. Certainly many categories, such as the basic emotions or schizophrenia, maintain the consistency of qualities that we associate with natural kinds. Negotiations over the ontological status of these categories can only be resolved through the shared insights of scientists and historians.5 Such negotiations should matter to historians since they shape the kind of histories we write. If psychological objects are straightforward human kinds then their history goes beyond the different approaches that investigators have brought to their study. It becomes a narrative of how these states have been brought into being and, through that process, have transformed our world.6 This kind of narrative raises three new interrelated problems. The first problem is that of continuity. If psychological categories are constituted through social, cultural, and material practices then there is no easy way to trace their stories across time and between cultures. There is no external unchanging referent that can act as a foundation for our narratives. Attempts to trace the ‘biography of a disease’ (for example, the development of Hippocratic melancholia into twentiethcentury clinical depression) run the risk of conflating very different forms of human existence and of subsuming different conditions under a single label. The second problem is that of reflexivity. Historians of mind and medicine (whatever their philosophical stripe) commit themselves to specific psychological and psychiatric models in their narratives and their work in turn serves to shape those models. Demonstrating the continuity or transience of a psychological object across time contributes to debates over its status as a natural kind. In this sense, writing the history of the psy-sciences cannot be separated from the actual practice of these disciplines. Historical writing on medicine and mind is not a mere rehearsal of events: it is an active intervention in arguments over aetiology and classification. It may even serve a

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therapeutic function, since it changes our understanding, experience, and embodiment of psychological states.7 History is thus bound up with every aspect of psychological medicine from classification to cure. The third problem is that of disciplinarity. The production of psychological theories is not the preserve of any professional group: it is an activity implicit in all accounts of human agency. Popular anecdotes, literary masterpieces, religious meditations, legal rulings, economic treatises, and philosophical systems all advance specific models of mind and human nature. Thus it requires a certain amount of work to establish the remit and authority of the mind sciences. In tracing their histories we are engaged in a kind of policing operation, demarcating those sanctioned ideas that contribute to the current self-image of the sciences from the dead-end conjecture of outsider speculation. Historical writing thus becomes an exercise in disciplinary self-definition.8 The ambiguous status of psychological objects creates an inextricable connection between history and the mind sciences, the depth of which is demonstrated by the standard textbooks in these disciplines. In striking contrast to their counterparts in biomedicine and life sciences, these textbooks have routinely been prefaced with historical introductions. The original English translation of Philippe Pinel’s Traité médico-philosophique l’aliénation mentale (1801)—widely regarded as the foundational text of modern psychiatry—opens with a forty-page history of insanity and its treatment.9 The leading nineteenth-century alienists including John Haslam (1764–1844), Jean-Etienne Esquirol (1772–1840), Daniel Hack Tuke (1827–95), BenedictAugustin Morel (1809–73), Wilhelm Griesinger (1817–86), and J. M. Charcot (1825–93) all published historical studies as did pioneer workers in psychoanalysis, psychotherapy, and psychosomatics in the twentieth century. Many different rationales animate these historical inquiries. In the late twentieth century, committed (and disaffected) psy-professionals have turned to historical material in debates over epidemiology, the impact of social policy, the limits of psychopathological models, the ethical and philosophical foundations of psychiatry, the nature of the unconscious, the role of commercial interests, the motivations of early psychoanalysts, and the ontological bases of psychological categories.10 History thus maintains an ambiguous role with regard to the mind sciences. It can be used to demonstrate the universality of psychological characteristics, capacities, and illnesses or it can serve to demonstrate their relative bases by revealing the implicit assumptions that guide modern research as well as the specific configurations of theory, practice, and technology that allowed the mind sciences to emerge and their subject-matter to be articulated. This chapter embraces this second approach. It outlines four broad constructions of the psyche—the inscribable, the historical, the adaptable, and the statistical—and shows how their articulation has made possible new kinds of self-understanding and social interaction. Although, as we have seen, broad claims are made for the universal basis of psychological phenomena, this discussion will focus on the specific conceptions of mental medicine that have emerged in Europe and North America since the end of the eighteenth century. This choice of a short timescale is deliberate. It is at this point that psychological

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language is invented: the language that makes possible our modern experience of mind, self, and mental illness.

The inscribable psyche Many of the elements of psychological medicine have a long history, but it was only at the end of the eighteenth century that they began to come together in the configuration that we recognize today. This configuration rests upon the belief that mind can be disordered through its own ideas or emotions (rather than disturbed humours or intervening passions) and rescued through psychological therapies and institutions. The appearance of this new framework can be traced through shifts in language, policy, medicine, and legal practice. The terms ‘psychology’, ‘psychiatry’, ‘psychotherapy’, and ‘psychosomatic’ all appeared at this moment. ‘Psychology’ was deployed in mideighteenth-century Germany to designate a science of mental life—although the word had appeared in earlier treatises on theology and pneumatology. ‘Psychiatry’ was coined in 1808 by the Romantic neurologist Johann Christian Reil (1759–1808) to designate a new science of mental medicine.11 ‘Psycho-somatic’ appeared in Samuel Coleridge’s Notebooks to designate the changes that the ‘Patient’s Mind produces in his body, without any intentional act of the Will’.12 ‘Psycho-therapy’ or ‘psychotherapeia’ was a later addition, being first used in 1853 to describe a science of mental balance.13 These neologisms condensed a series of developments dating back to the sensationalist philosophy of John Locke (1632–1704) and the Newtonian medicine of physicians such as William Cullen (1710–90). These developments underlined the idea that individual identity was not granted through the possession of reason or one’s position in society but arose instead out of personal experience and nervous organization. The inner life mirrored the Newtonian universe. It was composed of individual mental atoms (sensations and ideas) that combined according to natural laws. However, this order was fragile. Bodily stress and personal upsets could fracture these ordered combinations and tip the sufferer into illness and insanity. The restoration of inner order depended upon the active manipulation of these mental atoms: a process in which new associations were inscribed. In the remainder of this section, I want to concentrate on the development of two of these manipulative therapies—mesmerism and ‘moral therapy’—that have been held up respectively as the precursors of dynamic psychiatry and asylum care. Although histories of the discovery of the unconscious grant Franz Anton Mesmer (1734–1815) a foundational role, his position as a psychological pioneer rests upon a misapprehension.14 The magnetic philosophy that Mesmer articulated was not a psychological science, rather it was a form of holistic medicine in which both mind and body were treated through the manipulation of invisible electrical fluids. The conception of mesmerism as a psychotherapeutic system, restoring health through mental influence, only occurred when its claims were contested. Investigative commissions into mesmerism

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launched by the French government accepted the reality of the cures but claimed that their effects originated in the patient’s mind.15 Mesmerism became psychological when it ceased to be scientific. Through their attribution of therapeutic effects to the power of the imagination the commissioners transformed a physical intervention into a mental drama. By redefining the boundaries of the truth they redefined the margins of the mind. In the transformation of animal magnetism into a form of mental healing we can identify most of the processes raised in the opening discussion. First, we can see how the rhetorical deployment of a psychological concept—‘imagination’—to explain the mesmeric process led to that concept taking on new attributes and properties. Through a kind of subtle linguistic alchemy the imagination took on most of the capacities and characteristics originally associated with the magnetic healer. It was capable of acting upon the body, instilling and removing illnesses at whim. And like the charlatan mesmerist, the imagination was both deceitful and capable of being deceived. It could be duped into producing effects but could hide those effects’ true sources. Second, we can see how the language of mesmerism made available new ways of describing human actions, relationships, and identities. Intentional actions could now be redescribed as unconscious activities and changes in behaviour attributed to the individual’s transformative encounter with mesmeric ideas. Third, it made possible new forms of embodiment. It is striking that as the electrical concepts of animal magnetism gave way to a psychological model there was a corresponding transformation in the physical phenomena associated with these acts of healing. Whereas the patients at Mesmer’s early séances were thrown into convulsions (as a result of the electrical charge imparted to their bodies), the subjects of later mesmeric and hypnotic experiments fell into a cataleptic trance as they accessed unconscious aspects of the mind. The imaginative interventions of the early mesmerists were paralleled in the ‘moral treatment’ of insanity. The pioneers of this approach, Philippe Pinel (1745–1826), William Tuke (1732–1822), and Vincenzo Chiarugi (1759–1820) in Paris, York, and Florence, used a mixture of conversation, family care, and personal example to re-order the madman’s mind. A new emphasis on language and interaction now supplemented the Hippocratic prescription of diet, purges, and regimen. The ‘airs, waters and places’ that had formed the basis of the humoral approach were replaced by an emphasis on the patient’s cognitive environment. These methods of moral treatment seem to mirror twentieth-century psychotherapeutic interventions, yet they rest upon a very different set of assumptions. There was no attempt to recover the true source of the patient’s troubles in moral therapy; rather, as Pinel and Tuke made clear, theatre and trickery provided effective means for restoring mental order. Although later commentators may have sought to exploit the ethical connotations of this therapy, the word ‘moral’ was deployed here in its standard eighteenthcentury sense: it designated those aspects of mind outside the intellectual powers.16 The asylum emerged as an instrument for shaping minds and behaviour. Radical critics, such as Michel Foucault (1926–84) and Klaus Doerner (1933–), seized upon this aspect of the asylum’s work. In a rhetoric that was indebted to the

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language of moral therapy they depicted the asylum as a machine for reforming individuals, creating new identities dictated by the demands of bourgeois morality and industrial capitalism.17 According to Foucault, the new asylum replaced physical fetters with the controlling chains of individual conscience. These arguments, which combined a belief in the inscribable psyche alongside a Romantic faith in madness as a form of freedom, soon came under sustained assault from professional psychiatrists, philosophers, and historians who questioned their idea of mental illness and its assumed chronology.18 Although there were undoubted errors in Foucault’s grand narrative (errors that were compounded in the abridged English translation) the easy dismissal of his arguments is to be regretted. The significance of Foucault’s work lay in its synthesis of cultural politics, state-building, and individual identity formation. It paved the way for a new understanding of psychiatric power as a means of selfcreation and as a crucial component in the appearance of a new form of government that he termed ‘biopolitics’.19 Ignoring Foucault’s claims, most Anglo-American historians have treated the rise of the asylum as a problem of social policy, locating its development in economic, political, and demographic concerns. Debate centred upon the rapid expansion of the asylum system. Thus in Museums of Madness (1977), Andrew Scull attributed this growth to the social disruption wrought by nascent industrial capitalism and the decision of asylum keepers to extend the boundaries of insanity in order to generate new markets.20 Scull’s thesis turned what had been a medico-psychiatric question into a problem that could be analysed using the tools and methods of social and economic history. It inspired a detailed programme of research into patterns of asylum admission and discharge, the careers of competing alienists, and the administration of the Poor Law. These histories scrupulously avoided the pitfalls of psychohistory and retrospective diagnosis. Biological variables that might explain the rise in numbers (nutrition, alcoholism, or rates of syphilitic infection) were excluded. As with Foucault’s arguments, these accounts remained wedded to the mental models of the moral therapists. The patient’s psyche was a tabula rasa inscribed with the interests of lay asylum keepers, medical professionals, magistrates, and their own desperate families. It was ironic that despite their implicit commitment to the inscribable psyche of the moral therapists, these historians concentrated their studies on mid-nineteenth-century asylums: the very site upon which this model of the psyche would itself break down.

The historical psyche By the end of the nineteenth century the dream of moral treatment lay in tatters, the claims of the mesmerists were discredited, and the asylum project lamented as a humanitarian failure. Yet the psyche endured in a new and more complex form. It was no longer seen as a superficial combination of ideas animated by the passions and emotions, but as a phenomenon of mystery and depth extending to the deep history of

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the individual and the race. Its pathologies did not stem from internal disorganization but from the breakdown of the fragile boundary between the present and the past. Pathological conditions were mapped onto the patient’s racial inheritance or their unconscious traumas. This transformation was made possible by a range of new arguments, practices, and technologies that emerged across a number of independent sites including pathological anatomy, Romantic literature, electro-physiology, hypnotic investigations, and the asylum itself. These developments made visible the long history of the psyche and established the idea that it persisted outside the boundaries of the subject’s consciousness. Economic historians have explained the emergence of the historical psyche and the adoption of degenerationist ideas as intellectual rationalizations of the asylum’s failure and the exponential increase of the insane population.21 This functionalist explanation underestimates the asylum’s own role in the production of this historical perspective on psychopathology. The long-term segregation of the insane turned them into a distinct population and made visible the developmental histories of their illnesses. Their conditions were no longer seen as an unhappy reaction to the vicissitudes of life, but as morbid processes with specific aetiologies. This vision of illness was complemented by the theories of racial degeneration developed by B. A Morel (1809–73) and Moreau du Tours (1804–84) in the 1860s and the tradition of neuro-anatomical research initiated by Wilhelm Griesinger that mapped mental disorders onto specific cerebral lesions.22 These innovations shifted the therapeutic goals of asylum psychiatry: it moved from the restoration of individual conscience to the preservation of racial biology. Asylum policy combined with the evolutionary theories of Charles Darwin (1809–82) and Herbert Spencer (1820–1903) to place the population at the centre of psychiatric concern. Eugenic policies on the control of inebriates, habitual criminals, and the feeble-minded had been enacted across Western Europe and the United States as governments sought to prevent the spread of toxic elements in the social organism.23 The danger posed to the population by these atavistic elements was paralleled in the threat that primitive desires and morbid memories posed to the individual. Popular literature had long encouraged the idea that individuals might act according to unconscious agendas that secretly served some pathological need. By the 1880s this fictional trope had itself become incarnated in new forms of illness. Increasing numbers of patients presented with amnesias, hysterical fugues, multiple personalities, nervous breakdowns, and psychomotor disorders. Although these cases of psychic fragmentation appeared to demonstrate the frail nature of selfhood, hypnotic investigations by psychiatrists and psychical researchers revealed the subconscious persistence of personal memory and desire in the afflicted subjects. Streams of memory might fragment in moments of trauma and could be reintegrated into the normal consciousness through hypnotic interventions. The pioneers of the multiplex models of personality, Edmund Gurney (1847–88) and Frederic Myers (1843–1901), Hippolyte Bernheim (1840–1919) and Pierre Janet (1859–1947), argued that every aspect of individual behaviour, no matter how bizarre, could be tied back into the deep history of the subconscious psyche.24 For both the individual

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and the population, health lay in the recovery and integration of rogue primitive elements. This idea of an occult interior life, produced in the theatrical illnesses of the hysterics and the investigations of their doctors, was elaborated through the growing armamentarium of electrophysiological technology. Instruments such as the manometer, the kymograph, the galvanometer, the chronoscope, and the polygraph allowed readings to be made of acute changes in blood pressure, reaction time, or skin conductivity. Understood as privileged representations of emotion and desire, these readings could be used to sustain an idea of the authentic self that stood at odds with the subject’s own understanding of their inner life. As new technologies multiplied the number of signs that could be retrieved from the patient’s body, the historical psyche took on more complex characteristics. These developments were clearly expressed in the writings of Sigmund Freud (1856– 1939) and his followers in the psychoanalytic movement. In 1895, Freud and Joseph Breuer (1842–1925) published Studies in Hysteria, presenting hysterical symptoms as the symbolic expressions of traumatic experience. In The Interpretation of Dreams (1900) and The Psychopathology of Everyday Life (1901), Freud refined and extended his argument, treating ordinary aspects of human behaviour (from slips of the tongue through to nail-cutting accidents) as symptoms of conflicted desires. The body became the psyche’s confessional. As Freud noted: ‘He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his fingertips: betrayal oozes out of him at every pore.’25 The psyche described in these investigations maintained many of the attributes associated with mesmerism and moral therapy. Correctly managed it became a vital element in the achievement of physical health, an idea championed in the Mind Cure and Christian Science movements of North America.26 Yet it was imagined in very different terms. The unconscious was not simply a state produced through therapeutic interventions (as had been the case in mesmerism), but a deep complex of traumatic repressions and age-old desires made manifest in the individual’s mental and physical problems, hypnotic trances, word association tests, and electro-physiological recordings. This tension between the historical and the suggestive models of the unconscious underlined the problematic status of psychological knowledge. The possibility that psychological reports might simply be an artefact of introspective technique along with the lack of any agreed criteria for judging the truth of psychological explanations led to the development of new institutions to authorize and adjudicate different claims. In the late 1870s psychological laboratories were founded in Leipzig and Harvard, with successors soon appearing across the United States and Western Europe. In 1892, the American Psychological Association was founded, followed by the British Psychological Society in 1901. Although notions of the deep historical psyche may have been first articulated in the folk psychologies of the spiritualists and the yellow-back novels of the late nineteenth century, by the early twentieth century the psychological complex was subject to the professional claims of the incipient disciplines of psychology and psychiatry.

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The adaptive psyche The First World War is often seen as marking the apotheosis of the historical psyche. It is depicted as a hellish form of psychological enlightenment in which the horror of the conflict leads to a confrontation with the primitive animal desires that persisted beneath the veneer of Edwardian character: a process reinforced by the mass psychiatric breakdown of the participants and the new psychological therapies deployed in their treatment. Such narratives underestimate the clear hold that psychodynamic ideas had already achieved over medicine and the popular imagination in the years leading up to the war. The policing of national insurance schemes introduced psychologized versions of malingering in the early twentieth century and the forms of breakdown brought together under the demotic concept of ‘shellshock’ were already well established in cases of neurasthenia and railway spine. Thus although some may have originally seen the psychiatric history of the First World War as a kind of Manichean struggle between an old materialist military medicine and a new psychodynamic humanitarianism, recent investigators are more likely to emphasize the ways in which changes in diagnostic policy and the administration of military pensions made available new categories of illness and new ways of narrating personal experience.27 Although these new narratives relied upon biological models of instinct deployed in psychoanalysis they departed from its historical perspective. The psyche was not torn apart by ancient traumas, but compromised by its fitness in dealing with the current situation. Mental health was now seen as a crucial variable in economic power and military strength and funds became available for new programmes of psychiatric research. These programmes were predicated upon a model of the psyche that stressed its close involvement with the fabric of social life. Against the Freudian insistence on the biological autonomy of the unconscious, a new wave of renegade analysts and psychologists began to insist upon its social foundations. Alfred Adler (1870–1937) and Carl Jung (1875–1961) promoted rival models of the dynamic psyche that emphasized the role of social impediments and collective symbols in the generation of personal desires and internal complexes. In the work of Wilhelm Stekel (1868–1940), Trigant Burrow (1875–1950), Ian Suttie (1889–1935), and others the antagonistic relationship that Freud had set up between libido and society was discarded and those social forces that had once repressed the psyche now became the central components in its constitution. The psyche was seen as a social achievement and its pathological development, as Karen Horney (1885–1952) noted, arose from the capitalist promotion of competitive autonomy that frustrated the innate biological need to love.28 The psycho-social aetiologies developed in these theories were underwritten by the investigative techniques developed in the new discipline of sociology. In 1908, Émile Durkheim (1858–1917) proposed that suicides rates could be used as an index of the level of social integration in European nation-states. The combination of psychodynamic theories with these new survey techniques led to the creation of a kind of psychological

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economy in which rates of breakdown and psychosomatic illness could be taken as measures of mental health. In 1927, the Rockefeller Foundation established the Committee on the Relationships of Sociology and Psychiatry under the direction of the sociologist W. I. Thomas (1863–1947) and the psychiatrist Harry Stack Sullivan (1892–1949). The political significance of this new approach was demonstrated in the work of the Chicago School sociologists Robert Faris and Warren Dunham.29 Their much criticized study of the relationship between schizophrenia and social isolation showed how readings of psychological health could be used to benchmark economic and social organization. This culture of interdisciplinary research and the concomitant socialization of the psyche were made possible by the exploitation of two fluid biological concepts: ‘stress’ and ‘adaptation’. The words were elastic enough to serve as a kind of ‘creole’ linking together research programmes in physiology, biochemistry, neurology, endocrinology, psychosomatic medicine, clinical psychology, and military psychiatry. The physiological rationale for these interdisciplinary connections was found in the ‘fight or flight response’ described by Walter Cannon (1871–1945) in 1915 and the ‘general adaptation syndrome’ promoted by Hans Selye (1907–82) after 1936. Cannon and Selye argued that the body responded to environmental stress through the activation of endocrine glands and the autonomic nervous system. Prolonged activation of these systems generated a series of pathological effects ranging from gastric ulcers through to leucocytosis. The biological mechanisms, described in Cannon and Selye’s experiments, allowed for the embodiment of the many travails of modern existence.30 This physiological creole provided the basis for the new science of psychosomatic medicine. Pioneered by Franz Alexander (1891–1964) and Helen Flanders Dunbar (1902–59) in the late 1920s, this approach allowed psychological narratives to be attached to any number of physical symptoms.31 Although inspired by psychoanalytic ideas, particularly those of the maverick Berlin analyst Georg Groddeck (1866–1934), the psychosomatic approach abandoned Freudian obsessions with the individual’s deep history. Psychosomatic symptoms were seen as physiological concomitants of the psyche’s misguided attempts to adapt itself to stressful situations. In Freudian terms, they could be understood as ‘actual neuroses’ caused by the problematic discharge of unspent psychical energy rather than ‘psychoneuroses’ involving the conversion of ideas into physical symbols. In the theories of psychosomatic physicians the space of the psychological was transformed. It was no longer the expression of an internal symbolic life—it now simply referred to those processes that mediated between the biological individual and the wider environment. This language of stress and adaptation became central to Anglo-American psychiatric practice. The dominant philosophy of the interwar years, the ‘psychobiology’ of the Swiss émigré Adolf Meyer (1866–1950), depicted all abnormal behaviour as a failure of adaptive response.32 Although Meyer’s programme appeared to be extremely technical with its talk of ‘parergasis’ and ‘merergasic reactions’, the looseness of his categories allowed for the development of complex aetiologies in which the physical constitution of the patient and the strain imposed by life events provoked specific patterns of pathological reaction. This approach was indebted to the experimental successes of Ivan

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Petrovitch Pavlov (1849–1936) in the management of conditioned behaviour. Pavlov, like Cannon, provided a physical underpinning for pathological conduct without resorting to what the existentialist psychiatrist Karl Jaspers (1883–1969) would later dismiss as ‘brain mythologies’: the simplistic reliance on neuroanatomical lesions or defects to explain abnormal functioning. By the 1930s neurological problems were themselves recast as problems of adaptation. The holist neurologists Kurt Goldstein (1878–1965) and Karl Lashley (1890–1958) argued that normal and pathological responses drew upon information distributed across the cerebral cortex. The brain’s adaptive potential could be demonstrated through experimental interventions in which sections of the brain were ablated but function remained. The image of the psyche as a self-correcting mechanism prone to pathological maladaptation became enshrined in the psychiatric therapies of the interwar period. Although psychodynamic models were employed, the emphasis was on the recalibration and training of behaviour. This could be achieved through occupational therapies such as carpentry or through physical interventions. In 1935, the Portuguese neurosurgeon Egas Moniz (1874–1955) experimented with the use of leucotomy (surgical ablation of the frontal lobes) to remove psychotic behaviour. In 1938, Ugo Cerletti (1877–1963), an Italian psychiatrist, experimented with electro-convulsive therapy in the treatment of schizophrenia. Although convulsive treatments (such as insulin coma therapy and cardiazol/metrazol administration) were well established in psychiatric practice (in part because of theories of the biological antagonism of epilepsy and schizophrenia), these treatments combined with ideas of stress and homoeostasis and wartime developments in gunnery and radar work to create a new science of cybernetics. Cybernetics encapsulated the integrative potential of ideas of adaptation. Its enthusiasts, including psychiatrists, mathematicians, electro-physiologists, and management theorists, argued that the problems of mind, society, and behaviour could be reconceptualized around the idea of information. Devices such as the electro-encephalograph (EEG) and the wave analyser that had been developed to investigate the workings of the psyche now provided a metaphorical language for imagining its operation. The brain was envisioned as a kind of scanning machine that demanded occasional recalibration when it became trapped in cycles of positive and negative feedback. Ideas of individual authenticity broke down. Personality, as cyberneticians such as Norbert Wiener (1894– 1964) and William Grey Walter (1910–77) made clear, was simply a transient pattern in the broad flow of information. Taken to their logical conclusion, ideas of adjustment and adaptation dissolved the distinction between psyche and environment.33

The statistical psyche Histories of post-war psychiatry usually concentrate on the closure of mental hospitals and the rise of community care. They differ, however, in their explanations of this change. For some, the discovery of the anti-psychotic chlorpromazine in 1954 and the

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introduction of the tricyclic antidepressants and the monoamine oxidase inhibitors in 1957 are held up as bringing about a sea change in psychological medicine. Others argue that this process of ‘decarceration’ reflected deeper fiscal concerns of the post-war welfare states. Certainly there is good evidence that the fall in the mental hospital populations predates the introduction of the new psycho-pharmaceuticals. Moreover, both schools underestimate the extent to which the problems of psychiatry had changed. Ideas of mental illness and psychological health were imagined in very different terms from those held at the start of the century. In early twentieth-century psychiatry and psychotherapy, cure and aetiology were conflated. Understanding the traumatic origin of a neurosis or the hereditary roots of a psychosis made possible their alleviation. By the 1950s the association of historical truth with individual cure had broken down. Enthusiastic modernizers such as William Sargant (1907–88) decried the claims of psychoanalysis, advancing in its place a form of brief psychotherapy in which quick confessions were elicited through the use of sodium amytal injections and ether inhalation.34 Confession was probably the wrong word, for, as Sargant recognized, the truth of the patient’s drug-induced disclosures bore no relationship to their therapeutic efficacy. Rather it was a moment of chemical catharsis that allowed the patient to reconstruct their sick personality. In this work, the connection between health and authenticity that had been foundational to the psychodynamic model was torn apart. In its place an alternative framework for thinking about the relationship between truth, health, and authenticity began to coalesce, a framework inspired by cybernetic ideals and grounded in the new statistical instruments of the rating scale and the questionnaire. These new statistical instruments were bound up with the rapid expansion of clinical psychology after 1945. Tools that had been central to the academic investigation of personality and intelligence in wartime recruitment were now used to assess illness and treatment. The Minnesota Multiphasic Personality Inventory, first developed in 1940 and refined in 1952, was used to operationalize the psychiatric interview. At Stanley Royd in Leeds, Max Hamilton (1912–88) developed rating scales for anxiety (1959) and depression (1960). In London, Hans Eysenck (1916–97) devised a series of tests for measuring levels of neuroticism, introversion, extroversion, and later ‘psychoticism’ in the patient. These culminated in the Maudsley Personality Inventory (1959) and the Eysenck Personality Questionnaire (1964) that allowed individual characteristics to be represented on a numerical matrix. The questionnaires created a new material domain for the psyche—whereas its characteristics had once been revealed through the shape of the patient’s illness or in moments of unguarded speech, they now took the form of aggregated scores processed through the punched cards of early calculating machines. The paper psyche described in the tests of the cognitive psychologists touched almost every aspect of the psychiatric enterprise. The new rating scales were used to assess therapeutic efficacy, assemble populations for clinical trials, provide criteria for admission and discharge, and measure the extent of illness in the community to assist in the central planning of the mental health services. These surveys were usually undertaken in primary care settings: indeed it was a central contention of the questionnaire-makers

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that the greater part of mental ill-health (the ‘clinical iceberg of minor neuroses’) remained beneath the threshold of hospital consultation. The use of these instruments in general practice generated novel insights. Variations in reported rates of neuroses between practices could be either read as indications of social, economic, and geographic difference or dismissed as diagnostic artefacts generated by the psychological preconceptions of the individual physician. An instrument (the social survey) that had been fashioned to reveal the psychological state of the population now worked to reveal the personal idiosyncrasies of investigating doctors. This reflexive awareness of the psychological significance of the clinical encounter received its most thorough investigation in the work of Michael Balint (1896–1970) and his colleagues at the Tavistock Clinic during the 1950s.35 Psychoanalytic ideas persisted in primary care with close attention paid to the placebo-genic potential of the physician’s personality. Different models of the psyche developed on the different sites of psychological medicine. Whereas general practitioners still sought to exploit their knowledge of the patient’s biography and environment to uncover pathogenic secrets, hospital psychiatrists and clinical psychologists concentrated on more pragmatic forms of behaviour modification. Inspired by Pavlov and John B. Watson (1878–1958), they trained patients to cope with painful stimuli through processes of reward (‘operant conditioning’) or overexposure (‘systematic desensitization’). These ideas were developed by the American B. F. Skinner (1904–90) and émigré South African Joseph Wolpe (1915–97). Albert Ellis (1913–2007) and Aaron Beck (1921–) embraced the questionnaire method and laid the foundations for ‘cognitive behavioural therapy’ (CBT). These therapies were modelled on the logic of the rating scale. They sought to recalibrate responses along a continuum of personal behaviour. The connection between statistical analysis and psychological interpretation received its most significant exposition in the development of the clinical trial. First developed by the Cardiff psychiatrist Linford Rees (1914–2004) in 1950, the randomized control trial soon became the standard measure of drug assessment. In 1954, the Danish psychiatrist Mogens Schou (1918–) employed placebo-controlled trials to test John Cade’s (1912–80) use of lithium in the treatment of mania. That same year, a number of experimental trials endorsed claims by Jean Delay (1907–87) and Henri Deniker (1917–98) regarding the anti-psychotic potential of chlorpromazine. The apparent success of chlorpromazine and its commercial return led to a period of intense psychopharmacological innovation that in turn cemented the position of the clinical trial. In 1963, the US Food and Drug Administration made randomized control trials a mandatory element in drug development. The claims of the new pharmacology were bound up with the clinical trial: it was designed to establish particular kinds of truth. ‘Real’ effects were generated through biochemical interventions: the placebo responses of control groups were simply the background noise of inchoate psychological processes. The randomized controlled trial (RCT) was predicated on neo-Kraepelinian ideas of the discrete bases of psychiatric illness, but its attention to each variable in the procedure meant that these illness categories could always be contested and refined. By the 1970s, critics were claiming that

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psychiatry was suffering ‘diagnostic creep’ with more and more aspects of everyday life becoming the targets of medical intervention.36 The successive editions of the Diagnostic and Statistical Manual of the American Psychiatric Association (APA) bear witness to this process. When first published in 1952, it listed 106 disorders; by the time of its fifth revision in 1994, 297 conditions were recorded. In this process of constant revision, old frameworks, such as the psychodynamic approach, were abandoned and in the struggle between competing schools, the political and commercial interests that lay behind the scheduling of disorders became apparent. It was the active lobbying of APA conferences from 1970 to 1973 that led to the removal of homosexuality as a mental illness and its replacement by the more general ‘sexual orientation disorder’. At the same time the close involvement of pharmaceutical companies in the testing and application of new pharmacotherapies led to the suspicion that the invention of new psychiatric conditions was closely bound up with the development of new drugs.37 A neuro-pharmacology of everyday life emerged in which problematic aspects of ordinary behaviour, such as shyness or sadness, were opened up to pharmaceutical solutions. Perhaps the most dramatic example of this process was the rise of so-called ‘cosmetic psychiatry’, in which the discipline’s therapeutic goals moved from the recovery of the lost healthy self to the production of the identities that we want. Although many cultural commentators attributed this transformation to the new generation of antidepressants—the selective serotonin reuptake inhibitors (SSRIs) that were released under the trade names of Zoloft, Paxil, and Prozac (among others) in the 1980s—this was only one aspect of a broader cultural transition. The availability of pharmaceutical solutions to everyday problems moved the boundary of what need be tolerated and hence what could be considered normal behaviour. At the same time it contributed to a willingness to read life problems in medical terms. The psyche is understood as a vulnerable entity at risk from internal and external threats to be managed through psycho- and pharmacotherapy. Through an ongoing process of extension, medicine lost its therapeutic role and became part of the fabric of everyday living. Cosmetic psychiatry rested upon the separate developments described in the previous paragraphs: the breakdown of the boundary between the normal and the abnormal; the growth of an instrumental approach to character; and a new faith in the power of neurochemical interventions.

Conclusion The confusion of faith and biology in contemporary psychiatry returns us to the close involvement of historical writing with medicine and the mind sciences. Each of the issues identified in the introduction—the problems of disciplinary boundaries, reflexivity, and the ontological status of psychological objects—have been raised in latetwentieth-century psychiatry. In the first instance, a mixture of clinical, political, and pharmaceutical developments broke down the relationship between psychopathology and the asylum and expanded its remit across the population. At the same time this

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mixture changed the mission of psychological medicine: it was no longer a simple therapeutic intervention, it was the basis of a way of life. This conflation of psychiatry and identity formation raises the issue of reflexivity. It re-ignites old arguments first developed in anti-psychiatry, a movement that provided much of the intellectual impetus for the historical and sociological studies of medicine and mind that followed. Coined in 1967 by the existentialist physician David Cooper (1931–86), ‘anti-psychiatry’ was in many ways an inaccurate term. It did little justice to the wide range of positions subsumed under the label and it disguised the roots of the counter-movement’s rhetoric in mainstream psychiatry. Its focus on the power of hospitalization and its role in shaping behaviour grew out of post-war psychiatric studies of the problem of ‘institutional neurosis’ and indeed most of the movement’s leading practitioners, R. D. Laing (1927–89), Michel Foucault, Thomas Szasz (1920–), and Cooper himself, had received psychiatric or psychological training. In common with the new psychiatry championed by Sargant and others, the movement questioned notions of authenticity, describing instead how a patient’s illness and identity were formed through episodes of clinical role-play. Thus Thomas Szasz’s fierce critique of the ‘myth of mental illness’ developed from his work as a US Navy psychiatrist investigating cases of suspected malingering. He understood the psychiatric encounter as a rhetorical contest in which patient and therapist negotiated around biological categories to their political advantage.38 Although many historians would reject Szasz’s libertarian agenda and Laing’s late embrace of a transcendentalist psychology of liberation, the tools formed in these critiques formed the basis for subsequent historical investigations. The stories told by historians have concentrated on the political function of the asylum and the ways in which diagnoses served the conflicting interests of governments, families, patients, and doctors. The involvement of psychiatric ideas in shaping historical writing extends into the implicit ontologies that historians employ. Historical writing on psychology and psychiatry carries the dual risk of naturalizing or reifying conventional categories while at the same time failing to recognize the reality and consistency of individual conditions. Most social historians, with the notable exception of Edward Shorter, have been uncomfortable with the idea that history should surrender to epidemiology. They refuse to grant biological objects, such as the syphilis bacterium, a determinative role in historical narratives. At the same time, they have been wary of writing off cures and therapies to placebo effects. Although these effects have been subjected to sustained investigation by pharmacologists, psychologists, anthropologists, and clinical scientists, most historians, bar Anne Harrington and David Harley, have ignored the placebo’s potential confusion of biology and culture. This self-denying ordinance is unfortunate.39 The operation of placebo is a pre-eminently historical phenomenon that brings together contemporary beliefs and the mutable body. The placebo effect provides a physiological sketch map of our transformed expectations of science and our changing faith in medical authority. Clinical trials provide good evidence of this faith. Placebo response rates in anti-depressant trials are high and appear to be increasing.40 It is unlikely that this increase reflects a rapid biological change: rather it provides a

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demonstration of how our changing ideas of medicine are somehow working themselves into our physiology. The evidence for this transformation of attitudes is made visible by the randomized control trial rather than the archival and textual sources normally relied upon by historians. It shows how psychiatry and pharmacology have generated a very different set of tools through which we might craft our future histories.

Acknowledgements I am grateful to the Wellcome Trust for supporting this work and to Katherine Angel, Thomas Dixon, Leonie Gombrich, Mark Jackson, and Mathew Thomson for their comments.

Notes 1. E. A. Burtt, The Metaphysical Foundations of Modern Physical Science (London: Dover, [1932] 2003), 318–19. 2. Richard Rorty, Philosophy and the Mirror of Nature (Princeton, NJ: Princeton University Press, 1980); R. M. Young, ‘The Mind-Body Problem’, in R. C. Olby, G. N. Cantor, J. R. R. Christie, and M. J. S. Hodge (eds), Companion to the History of Science (London: Routledge, 1990), 702–11. 3. Kurt Danziger, ‘Natural Kinds, Human Kinds and Historicity’, in W. Maiers, B. Bayer, B. Duarte Esgalhado, R. Jorna, and E. Schraube (eds), Challenges to Theoretical Psychology (North York, ON: Captus, 1999), 78–83. 4. Ian Hacking, Historical Ontology (Cambridge, MA: Harvard University Press, 2002). 5. Rachel Cooper, Psychiatry and the Philosophy of Science (Stocksfield: Acumen, 2007), Chapter 4; Louis Charland, ‘The Natural Kind Status of Emotion’, British Journal for the Philosophy of Science, 53 (2002), 511–37. 6. Alisdair MacIntyre, ‘How Psychology Makes Itself True—or False’, in Sigmund Koch and David Leary (eds), A Century of Psychology as Science (Washington, DC: American Psychological Association, 1992), 897–903. 7. R. Powell, R. Dolan, and Simon Wessley, ‘Attributions and Self-Esteem in Depression and Chronic Fatigue Syndromes’, Journal of Psychosomatic Research, 34 (1990), 665–73. 8. Graham Richards, ‘Of What is History of Psychology a History?’, British Journal of the History of Science, 20 (1987), 201–11. 9. P. Pinel, A Treatise of Insanity (Sheffield: J. Cadell, 1806), xv–lv. 10. Edward Hare, On the History of Lunacy (London: Gabbay, 1998); E. Fuller Torrey and Judy Miller, The Invisible Plague: The Rise of Mental Illness from 1750 to Present (New Brunswick, NJ: Rutgers University Press, 2001); George Rosen, Madness in Society: Chapters in the Historical Sociology of Mental Illness (London: Routledge and Kegan Paul, 1968); Gerald N. Grob, The Mad among Us: A History of the Care of America’s Mentally Ill (New York: Free Press, 1994); Aubrey Lewis, The State of Psychiatry

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11. 12. 13.

14.

15. 16.

17.

18.

19. 20. 21.

rhodri hayward (London: Routledge and Kegan Paul, 1967); German Berrios, A History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century (Cambridge: Cambridge University Press, 1995); Gregory Zilboorg, A History of Medical Psychology (New York: Norton, 1941); Thomas Szasz, The Manufacture of Madness (London: Paladin, 1971); Klaus Doerner, Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry (Oxford: Blackwell, 1981); Michel Foucault, Madness and Civilization (London: Tavistock, 1967); Alan Gauld, A History of Hypnotism (Cambridge: Cambridge University Press, 1992); Leon Chertok and Isabelle Stengers, A Critique of Psychoanalytic Reason (Stanford, CA: Stanford University Press, 1992); Mikkel Borch-Jacobsen, The Freudian Subject (Stanford, CA: Stanford University Press, 1988); David Healey, The Creation of Psychopharmacology (Cambridge MA: Harvard University Press, 2002); Ernest Jones, Sigmund Freud: Life and Work (London: Hogarth Press, 1953–7); Kurt Eissler, Victor Tausk’s Suicide (New York: International Universities Press, 1983); Jeffrey Masson, Against Therapy (London: Fontana, 1990); Graham Richards, Putting Psychology in its Place (London: Routledge, 1991); Kurt Danziger, Naming the Mind (London: Sage, 1997). R. J. Richards, The Romantic Conception of Life: Science and Philosophy in the Age of Goethe (Chicago: Chicago University Press, 2002). Samuel Taylor Coleridge, Shorter Works and Fragments II, ed. H. J. Jackson and J. R. de J. Jackson (Oxford: Oxford University Press, 1995), 913. W. C. Dendy, Psyche: A Discourse on the Birth and Pilgrimage of Thought (London: Longman, Brown, Green and Longmans, 1853). See also Sonu Shamdasani, ‘Psychotherapy: The Invention of a Word’, History of the Human Sciences, 18 (2005), 1–22. Certainly most histories of the ‘discovery’ of the unconscious grant Mesmer a foundational role. See Pierre Janet, Psychological Healing: A Historical and Clinical Study (London: Allen and Unwin, 1924); Henri Ellenberger, The Discovery of the Unconscious (London: Fontana, [1970] 1992); Adam Crabtree, From Mesmer to Freud: Magnetic Sleep and the Roots of Psychological Healing (New Haven, CT: Yale University Press, 1993). Anne Harrington, The Cure Within: A History of Mind-Body Medicine (New York: Norton, 2008), 51. L. C. Charland, ‘Benevolent Theory: Moral Treatment at the Retreat’, History of Psychiatry, 18 (2007), 61–80; T. M. Dixon, ‘Patients and Passions: Languages of Medicine and Emotion, 1789–1850’, in F. Bound-Alberti (ed.), Medicine, Emotion and Disease, 1700–1950 (Basingstoke: Palgrave, 2006), 22–52. Foucault, Madness and Civilzation; Doerner, Madmen and the Bourgeoisie; Robert Castel, ‘Moral Treatment: Mental Therapy and Social Control in the Nineteenth Century’, in Stanley Cohen and Andrew Scull (eds), Social Control and the State (Oxford: Robertson, 1983), 248–66. Peter Sedgwick, Psycho-Politics (London: Pluto Press, 1982), Chapter 5; Jacques Derrida, ‘Cogito and the History of Madness’, in Writing and Difference, trans. Alan Bass (Chicago: University of Chicago Press, 1978), 31–63; Arthur Still and Irving Velody (eds), Rewriting the History of Madness: Studies in Foucault’s ‘Histoire de la Folie’ (London: Routledge, 1988). Michel Foucault, Society Must Be Defended (London: Penguin, [1975–6] 2003). Andrew Scull, Museums of Madness (London: Allen Lane, 1979). Laurence J. Ray, ‘Models of Madness in Victorian Asylum Practice’, Archives of European Sociology, 22 (1981), 229–64.

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22. Wilhelm Griesinger, Mental Pathology and Therapeutics (London: Hafner, [1867] 1965). 23. Robert Nye, ‘Rise and Fall of the Eugenics Empire: Recent Perspectives on the Impact of Biomedical Thought in Modern Society’, Historical Journal, 36 (1993), 687–700; Daniel Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (Cambridge, MA: Harvard University Press, 2005). 24. Gauld, A History of Hypnotism, 319–418; R. Hayward, Resisting History (Manchester: Manchester University Press, 2007), Chapter 2. 25. S. Freud, ‘Fragment of an Analysis of a Case of Hysteria’ [1905], Standard Edition 7 (London: Hogarth Press, 1977), 77–8. 26. Eric Caplan, Mind Games: American Culture and the Birth of Psychotherapy (Berkeley: University of California Press, 1989). 27. Tracey Loughran, ‘Masculinity, Shell Shock, and Emotional Survival in the First World War, (review no. 944)’, http://www.history.ac.uk/reviews/review/944, accessed 28 August 2010. 28. Karen Horney, The Neurotic Personality of Our Time (London: Kegan Paul, 1937). 29. R. E. Faris and H. W. Dunham, Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses (Chicago: University of Chicago Press, 1939). 30. Mark Jackson, The Age of Stress: Science and the Search for Stability (Oxford: Oxford University Press, forthcoming). 31. Franz Alexander, The Medical Value of Psychoanalysis (London: Allen and Unwin, 1932); Helen Flanders Dunbar, Emotions and Bodily Changes: A Survey of Literature on Psychosomatic Interrelationships, 1910–1933 (New York: Columbia University Press, 1935). 32. Andrew Scull and Jay Schulkin, ‘Psychobiology, Psychiatry and Psychoanalysis: The Intersecting Careers of Adolf Meyer, Phyllis Greenacre and Curt Richter’, Medical History, 53 (2009), 5–36. 33. Norbert Wiener, The Human Use of Human Beings (London: Eyre and Spottiswoode, 1950); William Grey Walter, The Living Brain (London: Duckworth, 1953); Andy Pickering, The Cybernetic Brain: Sketches of Another Future (Chicago: University of Chicago Press, 2010). 34. William Sargant, Battle for the Mind (London: Heinemann, 1957). 35. M. Balint, The Doctor, His Patient and Their Illness (London: Pitman Medical, 1956); Thomas Osborne, ‘Mobilizing Psychoanalysis: Michael Balint and the General Practitioners’, Social Studies of Science, 23 (1) (1993), 175–200. 36. Allan Horwitz and Jerome Wakefield, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (Oxford: Oxford University Press, 2007); Stuart Kirk and Herb Kutchins, Making Us Crazy: DSM—The Psychiatric Bible and the Creation of Mental Disorders (London: Constable, 1999). 37. David Healy, ‘Shaping the Intimate: Influences on the Experience of Everyday Nerves’, Social Studies of Science, 34 (2004), 219–46. 38. Thomas S. Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (London: Paladin, [1961] 1975). 39. David Harley, ‘Rhetoric and the Social Construction of Illness and Healing’, Social History of Medicine, 12 (1999), 407–35; Anne Harrington, The Placebo Effect: An Interdisciplinary Exploration (Cambridge, MA: Harvard University Press, 1997). 40. A. Lakoff, ‘The Mousetrap: Managing the Placebo Effect in Antidepressant Trials’, Molecular Interventions, 2 (2002), 72–6.

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rhodri hayward

Select Bibliography Berrios, German, A History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century (Cambridge: Cambridge University Press, 1996). Borch Jacobsen, Mikkel, Making Minds and Madness: From Hysteria to Depression (Cambridge: Cambridge University Press, 2009). Bound-Alberti, Fay (ed.), Medicine, Emotion and Disease, 1700–1950 (Basingstoke: Palgrave, 2006). Danziger, Kurt, Naming the Mind: How Psychology Found Its Language (London: Sage, 1997). Ellenberger, Henri, The Discovery of the Unconscious (London: Fontana Press, [1970] 1992). Harrington, Anne, The Cure Within: A History of Mind-Body Medicine (New York: Norton, 2008). Luhrmann, T. M., Of Two Minds: The Growing Disorder in American Psychiatry (London: Vintage, 2001). Rosen, George, Madness in Society: Chapters in the Historical Sociology of Mental Illness (London: Routledge and Kegan Paul, 1968). Scull, Andrew, Most Solitary of All Afflictions: Madness and Society in Britain, 1700–1900 (New Haven: Yale University Press, 1993). Shorter, Edward, A History of Psychiatry: From the Age of the Asylum to the Age of Prozac (New York: Wiley, 1997). Smith, Roger, ‘The History of Psychological Categories’, Studies in the History and Philosophy of the Biological and Biomedical Sciences, 36 (2005), 55–94. Thomson, Mathew, Psychological Subjects: Identity, Culture and Health in Twentieth-Century Britain (Oxford: Oxford University Press, 2006).

chapter 30

medica l ethics a n d th e l aw a ndreas-holger m aehle

Over the past twenty years, the history of medical ethics has developed into a strong sub-field of the history of medicine. To some extent, the development of this research area has benefited from the rise of bioethics. In fact, not only historians, but also medical ethicists and bioethicists have contributed to the field. Medical ethics, broadly understood as the area of thought and action pertaining to moral values in health and medicine, is now widely held to be co-extensive with the history of medicine, thus spanning—in different manifestations—across all historical periods and cultures. A recent expression of this perspective is the voluminous Cambridge World History of Medical Ethics, edited by American philosophers Robert Baker and Laurence McCullough. Its numerous international contributors examine discourses on medical ethics from all parts of the world since ancient times, up to and including the recent debates of bioethics.1 Readers seeking specific information on virtually any topic in the field should be well served when consulting this comprehensive work. The remit of the present chapter is not to attempt a précis of the history of medical ethics (which would be incomplete in any case in view of the wealth of historical sources, accounts, and themes), but to reflect on some historiographical focal points and trends in the recent scholarly literature on the history of medical ethics and bioethics. In doing this, I will also touch on historical relationships between normative thought and legal regulations. My analysis will focus on three key issues: the nature and motivations of traditional medical professional ethics; the history of ethical abuses in clinical experimentation and their consequences for regulation; and the rise of bioethics. At the end of the chapter, I will point to future directions in the historiography of medical ethics.

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‘Medical ethics’: etiquette or genuine ethics? The introduction of the term ‘medical ethics’ is usually attributed to the publication in 1803 of the book of the same title by Manchester physician Thomas Percival (1740–1804). The historical circumstances of its production are quite well known: Percival, as a senior consultant attached to the Manchester Infirmary and successful author on moral questions, was asked by the institution’s physicians and surgeons to compose regulations for the hospital in the aftermath of an internal dispute about an increase of its honorary staff. Going beyond this initial request, Percival drafted a text entitled Medical Jurisprudence (1794), which covered both public and private practice and which he circulated widely among his medical and literary friends. By 1803, he had developed the text into a comprehensive treatise, discussing hospital practice, private or general practice, the relationship to apothecaries, and ‘cases, which may require a knowledge of Law’. The title had been changed to Medical Ethics on the advice of some of his friends, although Percival adhered to the view that the term ‘jurisprudence’ included ‘moral injunction as well as positive ordinances’.2 Written in an aphoristic style and providing the reader with precepts of appropriate conduct, Percival’s book lent itself to being used as a code of ethics for the nascent medical professional societies of the nineteenth century, especially in America, where regularly trained physicians and surgeons strived to demarcate themselves from ‘irregular’ healers. Importantly it served as the basis for the Code of Ethics of the American Medical Association (AMA), adopted in 1847, the year after the Association’s foundation.3 Percival’s text on medical ethics had several, more or less immediate predecessors, most notably the Lectures on the Duties and Qualifications of a Physician (1772) by the Edinburgh professor of medicine John Gregory (1724–73), and the chapter on physicians in the more broadly conceived Enquiry into the Duties of Men in the Higher and Middle Classes of Society in Great Britain (1794) by the Revd Thomas Gisborne (1756–1846), who was one of the recipients of Percival’s circulated manuscript. However, neither Gregory’s more philosophically grounded lectures, which, as Laurence McCullough has argued, applied David Hume’s concept of sympathy to the ethics of medical practice, nor Gisborne’s contribution, which brought, as Roy Porter has suggested, a Christian gentleman’s morals to the topic, exerted the significant influence on the development of medical professional ethics that Percival’s work had.4 In the traditional historiography of medical ethics, from Chauncey D. Leake’s re-edition of Medical Ethics in 1927 to its sociological appraisal by Jeffrey Berlant and Ivan Waddington in the 1970s, Percival’s type of ethics has been criticized for being overly concerned with the internal relationships of health professionals, or with medical etiquette, at the cost of an engagement with ‘real’ ethical problems in relation to patients and society. The blame for a subsequently narrowed or skewed conception of medical ethics has been apportioned to the original ‘misnaming’ (Leake) of Percival’s work and to the medical societies who instrumentalized

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this kind of ethics or etiquette to legitimize claims for a monopoly of the medical profession on the market for health care services.5 In fact, those historiographical interpretations reflect earlier criticisms, which had already been expressed in an international debate around 1900, about a need to teach ethics to medical students and incoming practitioners. The Berlin physician and psychologist Albert Moll (1862–1939), author of a comprehensive book on medical ethics published in 1902, then complained that in these discussions the so-called professional duties (Standespflichten) of the doctor were being overemphasized or even taken to be identical with ethical duties. Moreover, he claimed that offences against professional obligations (for example, against the prohibition of medical advertising) were judged by the profession more harshly than violations of ethical duties towards patients.6 However, the specific backgrounds to such criticisms, in history and historiography, are readily recognizable. Moll was shocked about the brutality of human experimentation in contemporary hospitals and university clinics, such as bacteriological inoculation trials on dying patients.7 Similarly, Leake was concerned about how health insurance schemes, group practice, and state medicine affected North American medical practice and the doctor–patient relationship in a climate of serious economic pressures during the 1920s.8 Berlant’s and Waddington’s assessments of the monopolizing functions of medical ethics should also be read against the background of wider criticisms of the social authority of the medical profession and, more generally, of authoritarian structures in Western society in the late 1960s and early 1970s.9 More recent interpretations of Percival’s Medical Ethics have arrived at different conclusions, highlighting its genuine ethical intentions: John Pickstone sees it as a conservative defence of a, by then threatened, civico-medical virtue ethic; and Robert Baker understands it as the manifestation of a social contract between a profession and society, and as the reflection of a shift from individual to collective decision-making in medicine. Yet, also these interpretations should be seen in the light of their authors’ specific historiographical approaches to the source: Pickstone’s reliance on a socio-political micro-history of late-eighteenth-century Manchester; and Baker’s commitment to identifying the philosophical core contents of medical ethics.10 Perhaps also the historiographical focus on Percival’s ethics as a whole needs to be qualified. Given its connection with the history of the AMA’s code, its prominent place in the AngloAmerican literature on medical ethics is easily understandable. On the other hand, the interpretative approach to medical ethics documents as instruments for increasing medical reputation and power has become common in the 1990s and has been extended to earlier historical periods. Vivian Nutton’s scholarly analysis of the Hippocratic Oath and other ethical texts in the Hippocratic corpus, such as Law, Precepts, and Decorum, emphasizes the reputational gain that their moral injunctions (for example, to do no harm, to keep confidentiality, and to refrain from sexual contact with patients) would have brought to the group of healers in ancient Greek society who professedly committed themselves to them.11 Also, the motive of enhancing the doctor’s reputation in the context of competition from other healers has been traced by Roger French and David Linden in the late medieval De cautelis medicorum (1495, Advice to Medical Men) of the Paduan physician-philosopher Gabriele de Zerbi (c.1435–1505)

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as well as by Andrew Wear and Roger French in early modern medical ethics texts, such as Friedrich Hoffmann’s Medicus Politicus (1738).12 The latter work was already part of the so-called savoir faire (‘know how’) literature of the Enlightenment that openly aimed at helping young medical practitioners to build up a lucrative clientele and to cover up insecurities in diagnosis and treatment by prudent behaviour.13 Nineteenth-century codes of medical ethics came to reflect professional politics rather than deep moral thought about the doctor–patient encounter or the doctor’s moral responsibilities to society. Though intended as instruments of professional solidarity, codes of ethics could become divisive, as has been shown by John Harley Warner in relation to debates in the 1880s on the notorious consultation clause of the AMA’s code of 1847. The clause prohibited consultation with practitioners who adhered to an ‘exclusive dogma’. While this applied in principle to all kinds of unorthodox or irregular healers, the main target became the homoeopathic physicians, who had usually undergone the same basic academic education as their regular colleagues. Liberal specialist physicians, particularly in New York, argued that such discrimination, based on competing systems of belief and practice, had become obsolete. Instead, scientific expertise should become the new measure of professional competence and integrity in medicine. In 1882, the Medical Society of the State of New York deleted the consultation clause from its code, and the AMA retaliated by refusing entry to the New York delegates at its annual meeting later in the same year. Conservative New York doctors formed in 1884 their own orthodox society, the New York State Medical Association, which restored the consultation clause. Only in 1903 did the AMA drop the prohibition against consulting with homoeopaths as part of a larger revision of its code, and the two New York societies subsequently merged.14 In other countries, such as Germany or Britain, codes of professional ethics were likewise subject to political negotiation. In 1889, after lengthy discussions, the annual assembly of the German Medical Association (Deutscher Ärztevereinsbund) adopted a set of principles for the ethics codes of its member societies, although eminent liberal physicians, such as the Berlin professor of pathology Rudolf Virchow (1821–1902), had been deeply sceptical about the need for codification and for regulation of medical practice. The German ‘Principles of a Medical Professional Code’ were primarily designed to defuse competition among practitioners in a time of perceived overcrowding of the profession. They prohibited medical advertising, including the misuse of specialist titles, announcement of cost-free treatment of patients (especially by outpatients’ clinics), underbidding in contracting with the health insurance funds (Krankenkassen), offering payments to third parties (for example, nurses, midwives, and pharmacists) to increase one’s clientele, prescription of patent medicines of unknown composition (so-called ‘secret remedies’), any attempts to poach a colleague’s patients (for example, during locum practice or as a consultant), and any disparagement of a colleague in public. In part, these rules had been taken from the existing codes of the medical district societies of Munich (1875) and Karlsruhe (1876). The Munich society’s code in turn was a translation of the AMA’s code of ethics of 1847.15 The British Medical Association (BMA), by contrast, remained reluctant about adopting such a code. A code of ethics composed by

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one of its members, the Shrewsbury doctor Jukes de Styrap (1815–99), was published in four editions between 1878 and 1895. Offered by its author in 1882 as a professional standard for the BMA, the association’s governing body, the Committee of Council, refused to adopt it. The text had developed, however, into a kind of semi-official guideline by the end of the nineteenth century. Drawing upon Percival’s work as well as the AMA’s code, it was adapted to the increasingly competitive climate also for British medical practitioners during that period.16 Scepticism about codes of ethics was partly linked with their more sinister implication, the exercise of professional discipline, a topic that historians have only recently begun to explore in greater detail.17 In Britain, the foundation of the General Medical Council (GMC) in 1858 had not only introduced mechanisms for controlling the standards of medical education but also for disciplining practitioners for ‘infamous conduct in any professional respect’. Initially, the punishment for professional misconduct was erasure from the GMC’s Register of licensed medical practitioners, but later merely temporary suspensions became increasingly common. Convictions during the nineteenth and early twentieth centuries pertained to matters such as covering unqualified assistants, improper use or fraudulent acquisition of qualifications and titles, advertising and canvassing, and false certifying, but also to committing adultery with patients and other sexual misconduct, abortion, drunkenness, and improper disclosure of confidential patient details, indicating thus a mix of concerns about violations of medical etiquette and ethics. Erased from the Register were also those practitioners who had been convicted of a criminal offence. Only from 1883 did the GMC issue guidance, in the format of brief ‘Warning Notices’, on what would constitute punishable professional misconduct. Russell G. Smith, who has compiled and analysed the GMC’s disciplinary cases between 1858 and 1990, has identified and criticized a traditional and long-lasting reluctance of the GMC to provide advance advice on correct conduct. This reluctance apparently featured as late as the 1980s, in the case of London physician Ann Dally (1926–2007) regarding the issue of bona fide prescription of controlled drugs for addicted patients.18 The GMC’s historical reticence in giving ethical guidance (which definitely ended, however, with the issuing to all registered medical practitioners of the booklet Professional Conduct and Discipline: Fitness to Practise, 1993) contrasts somewhat with the approach taken from early on in Germany, by the Prussian Medical Courts of Honour (Ärztliche Ehrengerichte). Introduced by legislation in 1899 and attached to the twelve provincial medical chambers, they had a central appeal court in Berlin, which regularly published collections of its decisions. Reports on the disciplinary cases were also published in the bulletin of the German Medical Association, the Ärztliches Vereinsblatt für Deutschland, and in other medical professional journals, such as the Berliner Ärzte-Correspondenz and the Münchener Medizinische Wochenschrift. In contrast to the British GMC, the courts of honour were not entitled to invalidate a doctor’s practising license, but they could and did extensively ‘punish’ with warnings, reprimands, fines, and withdrawal of voting rights in the chamber elections, thus aiming at the practitioner’s sense of professional honour. The most common disciplinary cases pertained to medical advertising, financial misconduct, slander or libel, sexual offences,

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so-called lack of collegiality, false certifying, practising at various places, refusing medical assistance, and links with non-licensed healers such as naturopaths. While there was a predominant concern in the Prussian courts of honour about intra-professional issues in a competitive environment, the doctor–patient relationship was considered as well, especially in the sexual sphere. This applied also to other states in Imperial Germany as well as to the period of the Weimar Republic. During the National Socialist dictatorship the medical courts of honour were centralized and forced into line like many other institutions. After 1945, in the professional courts of post-war West Germany, the ‘classic’ disciplinary cases of medical advertising and offences against collegiality continued to be prominent, in addition to refusing of medical assistance, sexual misconduct, misuse of titles, and offences in relation to fees and certificates.19 Thus, in the light of the more recent historical scholarship, the traditional view that medical ethics was essentially just etiquette in the relationships between practitioners needs to be qualified. Intra-professional issues were prominent in medical ethics, particularly towards the end of the nineteenth century, but this did not exclude concern for ethical behaviour towards the patient. For example, the conflict for doctors between their ethical duty to protect patients’ privacy and demands for disclosure of patient details in the interest of public health (especially in the fight against venereal diseases) has recently been highlighted in studies on medical confidentiality during the nineteenth and early twentieth centuries.20 Future research is likely to produce more evidence for the patient-oriented dimension of medical ethics, particularly through historical work that focuses on patients’ experiences and perceptions of medical treatments.21 Depictions of the doctor–patient encounter in art and literature can further elucidate this ethical dimension. Other sources that can help broaden our historical knowledge of medical ethics are the daily press as well as the news sections in medical journals.22 One area that has already brought the ethics of the doctor–patient relationship into sharp relief is the history of clinical experimentation, which will be discussed in the following section.

Abuses in clinical experimentation and their consequences for regulation The historiography of the ethics of human trials has often been linked to historical research into Nazi medicine, where the worst abuses happened in the experiments on concentration camp inmates.23 However, important work has also been done on attitudes of researchers to human subjects before and after the Second World War, with regard to Germany as well as other countries. In the United States, for example, the scandal of the Tuskegee Syphilis Study, which became public in 1972, and press reports in the 1990s about Cold War human radiation experiments created widespread interest in the topic. There are now substantial monographs on the history of human experimentation

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in Imperial Germany, in the United States during the twentieth century, and in France after 1945, as well as on the Nuremberg Doctors’ Trial of 1946/7.24 Moreover, several collections of essays on the history and ethics of human trials have been published over the past ten years.25 Chronologically, the origins of a critical public debate on human trials can be traced back to the late nineteenth century, when Western medicine’s confidence in a scientific, experimental approach to problems of health reached a first peak. Bacteriology then quickly established itself as the leading field of medical science. Characteristically (though not exclusively), public concern about ethical transgressions was linked to this area. Paradigmatic was the scandal around the experiments of the Breslau professor of dermatology Albert Neisser (1855–1916), who had discovered the gonorrhoea bacterium in 1879. In 1892, Neisser injected syphilitic blood serum into several of his hospital patients (some of them minors), in an attempt to develop an immunization against syphilis. Neither the patients, nor the legal guardians in the case of the children, had been informed about the nature of the injections or asked for their consent. Some of the test persons later developed syphilis. Although Neisser claimed that these were all prostitutes and had acquired the disease ‘naturally’, the scandal broke. The case went through the newspapers and was discussed in the Prussian parliament. As Barbara Elkeles has argued, much of the campaign against Neisser had anti-Semitic motives. Moreover, there were links with the German anti-vivisection movement, which—following the British example—strongly campaigned against experimental medicine during these years. One of the key moral arguments of the critics of animal experimentation, used since the seventeenth century, was that callous treatment of animals might result in the same attitude towards human patients. However, there was also genuine concern about the contemporary treatment of (mostly lower-class) patients in public hospitals and university clinics. In 1900, Neisser was officially disciplined with a reprimand and a fine for his failure to obtain consent and for having violated his responsibilities as a physician, director of a clinic, and professor.26 In the same year, the Prussian Ministry for Religious, Educational and Medical Affairs, alarmed by further reports of risky experimentation on patients, issued instructions to the heads of hospitals and clinics about the requirements for scientific experiments on human subjects. Such experiments were only permitted on informed and explicitly consenting adults (not on minors or other persons who were not fully competent in the legal sense), under the direct authorization by the head of the hospital or clinic. Moreover, they had to be recorded in the patient’s file. This was probably the first such regulation world-wide. On the other hand, medical interventions for ‘diagnostic, therapeutic and immunization purposes’ were excluded from these regulations, which left an ambiguous status for therapeutic experiments as well as for innovative diagnostic techniques and new vaccines.27 Only in 1931, when 76 newborns in the city of Lübeck had died after having received in a large trial (probably contaminated) BCG vaccine against tuberculosis, did the German Ministry of the Interior issue guidelines that required information and consent explicitly for therapeutic as well as non-therapeutic trials.28

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Although still in force during the Third Reich, the Guidelines of 1931 provided no protection for the subjects of human experimentation in the concentration camps. It has been estimated that over 8,000 Jewish, Roma, Russian, Polish, and other people became victims of the brutal experiments conducted by Nazi doctors and, as historical research in this area progresses, this number is likely to be corrected upwards.29 As was revealed during the Nuremberg Doctors’ Trial, experiments included exposure to high-altitude conditions (low air pressure) and rapid descent, freezing, forced drinking of sea-water, deliberate infection with malaria, epidemic jaundice, spotted fever, and other pathogens, exposure to mustard gas and phosphorus from incendiary bombs, artificial creation and experimental treatment of infected wounds (in particular gas gangrene), testing of methods for mass sterilization by radiation, chemical, or surgical means, tests of poisons for the ‘euthanasia’ programmes, and killing of subjects to obtain anatomical specimens. Many of the experiments were linked with questions of military medicine during warfare, but others were motivated by the racist anthropological and eugenic concepts of Nazi medicine. Almost 300,000 mentally ill, disabled, and other people (especially children) were killed in the Nazi ‘euthanasia’ programmes, and about 350,000 people were compulsorily sterilized. In the Nuremberg Doctors’ Trial, which lasted from December 1946 to August 1947, the American prosecutors and judges focused on the crimes related to human experiments. As a result of this trial, seven of the twenty-three defendants were hanged and nine sentenced to imprisonment from fifteen years to life.30 The judgement included the so-called Nuremberg Code, which had been developed during the trial as a guideline for permissible research on human subjects. The Code required the voluntary and fully informed consent of the test persons, who should have legal capacity to give such consent. Moreover, it contained several rules for providing protection for human subjects against risks to their health, including the subject’s right to withdraw from the experiment at any time and the demand for previous tests on animals. While the Nuremberg Code had the status of a document of international law, its relevance for ‘civilized’ Western medicine was subsequently questioned due to its origins from the persecution of Nazi criminals.31 Nevertheless, its provisions formed a basis for the Helsinki Declaration of 1964 of the World Medical Association (WMA). Revised several times at various WMA assemblies (Tokyo 1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000, and Seoul 2008), the Declaration of Helsinki is still internationally recognized as a code of ethics for medical research on human subjects, and its principles for the safe-guarding of valid consent and for the effective protection of the test persons have influenced many national legislations.32 However, the Declaration of Helsinki also reflected the beginning of a ‘watering down process’ (compared with the demands of the Nuremberg Code) that made allowances for the practical needs of researchers. As Susan Lederer has shown for the history of the 1964 version, attempts within the WMA to ban experiments on children in institutions and on ‘captive’ subjects, such as the inmates of mental asylums, prisons, and reformatories, were thwarted by the interests of the American pharmaceutical industry, which needed these subject populations for the testing of new drugs and vaccines.33 While the 1975 revision of the Helsinki Declaration introduced the requirement of independent

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review of research projects by ethics committees, the revisions in 2000 reflected the continuing tensions between research interests and efforts to strengthen protections for vulnerable subjects. Against the background of trials with new AIDS treatments in developing countries, the use of placebo controls even when a standard therapy is available for comparison became an issue, as did the question of guaranteeing post-trial access of the participants to the best treatment identified in a study.34 In its latest version (2008), the Helsinki Declaration permits such use of placebos only ‘for compelling and scientifically sound methodological reasons’ and where ‘the patients who receive placebo or no treatment will not be subject to any risk of serious or irreversible harm’ (section 32). Moreover, after conclusion of a study, the patients entered into it are entitled to ‘access to interventions identified as beneficial in the study or to other appropriate care or benefits’ (section 33).35 The recent historiography of human experimentation has demonstrated, again and again, how requirements of the Nuremberg Code or of the Helsinki Declaration have not been fulfilled by researchers, including state-funded researchers in Western countries such as Britain and the United States. The Tuskegee Syphilis Study between 1932 and 1972, in which approximately 400 African-American men were deliberately left untreated for syphilis and misinformed about their condition in order to study the natural progression of the disease, is only the most prominent example.36 The British physician Maurice Pappworth (1910–94) and the American anaesthesiologist Henry Beecher (1904–76) blew the whistle about risky clinical experimentation without sufficient informed consent during the late 1950s and 1960s in Britain and the United States.37 This has raised the more general question of the effectiveness of ethics codes as long as they are not sufficiently endorsed and enforced by legislation and mechanisms of institutional control.38 However, these codes can provide valuable guidance for ethics committees. During the late 1960s and early 1970s, teaching hospitals and many other hospitals in Britain set up specific committees to oversee the ethics of clinical research.39 In 1984, the Department of Health established Local Research Ethics Committees, which aim to protect human subjects on the basis of the principles of the Helsinki Declaration.40 Regarding historical abuses of human subjects, calls for greater attention of historians to the fate of the victims of experimentation have been made, also in view of compensation for survivors.41 Furthermore, the question whether it was permissible to use information from unethical human experiments of the past has not only been discussed regarding the Nazi period, but also for the Japanese biological warfare research on Chinese prisoners during the Second World War.42 Not all of this unethical research was, as has occasionally been maintained, scientifically obsolete already when it was carried out. As Volker Roelcke has recently shown for the sulphonamide experiments on artificially wounded concentration camp inmates in Nazi Germany, these were, as far as the scientific problems themselves were concerned, up-to-date for their time.43 New challenges for consent to research have been created over the past decade with the collection of genetic and health information about whole populations. With the parliamentary approval of the Icelandic Health Sector Database Act in 1998, the state of Iceland gave consent for all its citizens to be included in the ‘deCODE’ genetic and health

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database project. Citizens unwilling to take part must explicitly opt out.44 Opting-out, rather than the opting-in, has also become the policy for post-mortem organ donation in some countries (for example, Austria, Belgium, France, Spain, and Sweden) in order to deal with the shortage of organs for transplantation.45 The issues surrounding human organ donation and transplantation have become central to modern bioethics, whose development will be discussed in the next section.

The rise of bioethics The emergence of modern bioethics (or biomedical ethics) since the 1960s has been linked to various factors. As has been argued by David Rothman, medical ethics ceased to be a more or less exclusive field for doctors. In an increasingly technology-and science-oriented medicine, doctors became estranged from their patients. At the same time, theologians, philosophers, lawyers, and social scientists became heavily involved in discussions about ethical aspects of medical practice and influenced medical decision-making.46 This broadening of the defining power of what is moral in medicine has furthermore been seen as reflecting more general social transformations, especially in the United States, as expressed in the civil rights movement, the student revolts, and the feminist movement. The declaration of patients’ rights (in analogy to citizens’ rights and women’s rights) in the early 1970s provides a case in point for this interpretation. Moreover, as has been pointed out by Roger Cooter, reactions to Roman Catholic views on medical morality in issues such as contraception, abortion, and euthanasia were constitutive of modern medical ethics.47 Other factors, which have been especially highlighted by first-generation bioethicists such as Albert Jonsen, were biomedical innovations that challenged principles of traditional medical ethics.48 Although the moral problems as such were not new, they were undoubtedly discussed more intensely and with a wider audience. The expansion of medical research in the post-war and Cold War period put the no-harm principle to the test and reinforced concerns about insufficient patient information and consent (see above). Significantly, the US Congress established in 1974 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which was given the task of identifying the ethical principles for such research and to make recommendations on the circumstances that would justify its support by the federal government. In the 1960s, the introduction of chronic haemodialysis for kidney failure brought the problem of just allocation of scarce resources into sharp focus. Particularly revealing in this regard was the constitution of a selection committee at the Seattle Artificial Kidney Center. Composed of a surgeon, a theologian, a lawyer, and four further lay members meant to represent the community, it decided initially on a case-by-case basis which patients should gain access to the limited number of life-sustaining dialysis machines. In the course of its work the committee developed selection criteria based on age, gender, marital status, number of dependants, income, education, occupation, and

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past and expected performance, that is ‘social worth criteria’, which were controversially discussed by the media and ethicists alike.49 Kidney transplantation (since the mid-1950s) and heart transplantation (from 1967) likewise raised the problem of resource allocation, but in addition led to new considerations of the definition of death, which had traditionally been determined by the observation of respiratory and cardiac arrest. The definition of an ad hoc committee at Harvard Medical School in 1968 became influential for legislation. It introduced the brain death criterion as demonstrated by a flat-line electro-encephalogram and the lack of reflexes, permitting explantation of organs from the ‘dead’ donor’s body while blood circulation and respiration were maintained. The great expansion of transplant surgery led to controversy about how to procure organs and tissues ethically in the light of a demand that far exceeds the number of donations.50 In the United Kingdom, the transplantation of organs from dead bodies was regulated by the Human Tissue Act of 1961, which required either that the donor had made a request to that effect prior to death or that in the absence of such a request and with no evidence for an objection during lifetime, there was no objection from the surviving spouse or other relative against the organ donation. As renal transplants from living donors became increasingly common and a commercial trade in kidneys developed, Parliament passed the Human Organ Transplants Act 1989. It ruled out payment for organs and required that donor and recipient should usually be genetically related. With this legislation in place, over 5,000 people in the United Kingdom were on the national transplant waiting list in the year 2000, and about 1,000 people had died in the previous five years while waiting for a heart, lung, or liver transplant.51 In response to scandals involving organ and tissue retention without the relatives’ knowledge or consent, notably at the Bristol Royal Infirmary and the Alder Hey Children’s Hospital, a new Human Tissue Act was enacted in 2004 and a Human Tissue Authority established as a coordinating institution. This new Act, replacing the previous legislation, came fully into force for England, Wales, and Northern Ireland in 2006 and adopted an opting-in system, according to which the deceased person’s wishes regarding donation of their organs are paramount and relatives have no legal right to veto these wishes. The 2004 Act furthermore introduced the notion of ‘appropriate consent’, which can be given or withheld by the deceased person during their life, by a nominated representative (in the absence of a prior decision), or by a qualifying relative (if neither a prior decision has been made nor a representative nominated). Consent to a live donation of organs (usually a kidney) can be given by a capacitated child or adult. In view of the nevertheless continuing shortage of donor organs, proposals for a move to a strict ‘opting-out’ system, where transplantation is permitted unless the deceased person or a close relative has previously explicitly registered their objection, have been controversially discussed in Britain during the past few years.52 End-of-life issues as well as ethical issues at the beginning of life have determined bioethical discourse. High-profile cases have influenced discussions to such an extent that sometimes the history of bioethics has been perceived through the debates that surrounded such cases. For example, withdrawal of artificial respiration in cases of

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persistent vegetative state (PVS) was discussed through the case of Karen Quinlan in the United States, where the New Jersey Supreme Court in 1976 endorsed her parents’ request to withdraw ventilation.53 Similarly important in Britain was the case of teenage PVS patient Tony Bland, a victim of the Hillsborough football disaster, in whose case the High Court, the Appeal Court, and the House of Lords in 1993 declared the withdrawal of tube feeding as legal.54 Debates on abortion were focused through the case of Roe v. Wade (1973), in which the US Supreme Court ruled that state law could not restrict the right of a woman, in accord with her doctor, to have a termination of her pregnancy during the first trimester.55 A similarly iconic status in the history of bioethics was the birth of the first baby created through in vitro fertilization (IVF), Louise Brown, in 1978.56 As Jane Maienschein has recently commented on the Brown case and the subsequent history of IVF, there seems to be a pattern of public responses to ethically ambiguous developments in biomedicine: from initial enthusiasm to abhorrence to tolerance and wide-spread acceptance.57 Whether this will also be the fate of the big bioethical challenge of the early twentyfirst century, embryonic stem cell research and therapeutic cloning, remains to be seen. Following the ‘shock’ of the birth of the first cloned mammal, ‘Dolly’ the sheep, in 1996, debates arrived at a wide-reaching consensus in the moral rejection of human reproductive cloning. However, the discourse on somatic cell nuclear transfer into enucleated egg cells, to create human embryonic stem cell lines that would be compatible for transplantation into the somatic cell donor, continues. As with previous bioethical issues, embryonic stem cell science has provoked comments from a wide variety of interested parties—medical scientists, philosophers, theologians, social policy analysts, and others. Since the harvesting of embryonic stem cells involves the destruction of embryos— usually surplus embryos from IVF—at the blastocyst stage, the moral status of the human embryo became central to ethical discussions and many arguments from the abortion debates were repeated. However, ‘stem cell ethics’ has also become a global debate, in which not only the different moral sensibilities of different countries and cultures have come to the fore (reflected in widely different legal regulations), but concerns about exploitation of women as egg donors and worries about injustices in access to a future regenerative medicine have been expressed as well—especially in view of the developing countries.58

Conclusion There will be plenty of work to do for future historians of medicine to contextualize and explore this latest episode in the history of medical ethics as well as the development of biotechnology more generally. The complex relationships between ethical debates, policy formation, regulatory authorities, and legislation will provide a challenging field for future historical investigations. In connection with this area, the role that experts in biomedicine have played (and continue to play) in political decisions about public health

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and medicine should be a rewarding subject of critical historical analysis. The international nature of bioethical debates indicates a special demand for comparative historical studies. As German historians Heinz-Gerhard Haupt and Jürgen Kocka pointed out in the 1990s, comparative history can broaden our understanding of the formation of European modernity as well as help to overcome Eurocentric perspectives. The intercultural study of mentalities and practices, they suggested, would allow integrating structural, social, and cultural history.59 For the history of medical ethics, the comparative approach will be especially useful in elucidating similarities as well as contingencies of ethical systems and controls. Beyond this, a broader, interdisciplinary analysis of the continuing rise of bioethics as a cultural phenomenon remains a formidable task, in which historians might want to cooperate with social scientists, cultural theorists, and medical humanities researchers, among others. The increasingly prominent role of biomedical ethics in academia has contributed to marginalizing the history of medicine as a discipline within the medical faculties of some countries, such as Germany and the United States. In this situation, historians of medicine have asked what the historical perspective can contribute to the current bioethical discourse.60 Historical precedents, the historical preconditions for today’s ethical and policy decisions, and the formation of a critical perspective on present-day medicine are commonly cited as legitimizing the historical study of medical ethics, and of medicine as a whole. However, historians of medicine have also learnt from bioethics, putting now more structured and rigorous ethical questions to their sources. Despite the disciplinary competition, interaction between bioethics and the history of medicine may thus drive the future research agenda. In search of greater social impact for their research, medical historians may also increasingly seek the input of the potential beneficiaries of their work—clinicians, patient groups, health lawyers, health policy makers, and others—about the kind of issues that require critical historical assessment. The future of the history of medical ethics in such an interdisciplinary environment looks thus very promising.

Notes 1. Robert B. Baker and Laurence B. McCullough (eds), The Cambridge World History of Medical Ethics (New York: Cambridge University Press, 2009). 2. Chauncey D. Leake (ed.), Percival’s Medical Ethics (Huntington, NY: Krieger, 1975), xxiii. 3. Robert Baker, ‘The Historical Context of the American Medical Association’s 1847 Code of Ethics’, in idem (ed.), The Codification of Medical Morality, vol. 2: Anglo-American Medical Ethics and Medical Jurisprudence in the Nineteenth Century (Dordrecht: Kluwer Academic, 1995), 47–63. 4. Lau rence B. McCullough, ‘John Gregory’s Medical Ethics and Human Sympathy’, in Robert Baker, Dorothy Porter, and Roy Porter (eds), The Codification of Medical Morality, vol. 1: Medical Ethics and Etiquette in the Eighteenth Century (Dordrecht: Kluwer Academic, 1993), 145–60; Roy Porter, ‘Thomas Gisborne: Physicians, Christians and Gentlemen’, in Andrew Wear, Johanna Geyer-Kordesch, and Roger French (eds), Doctors and Ethics: The Earlier Historical Setting of Professional Ethics (Amsterdam: Rodopi, 1993), 252–73.

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5. Leake, Percival’s Medical Ethics, 1–2; Jeffrey L. Berlant, Profession and Monopoly: A Study of Medicine in the United States and Great Britain (Berkeley: University of California Press, 1975); Ivan Waddington, The Medical Profession in the Industrial Revolution (Dublin: Gill and Macmillan, 1984). 6. Andreas-Holger Maehle, Doctors, Honour and the Law: Medical Ethics in Imperial Germany (Basingstoke: Palgrave Macmillan, 2009), 1. 7. Albert Moll, Ärztliche Ethik. Die Pflichten des Arztes in allen Beziehungen seiner Thätigkeit (Stuttgart: Ferdinand Enke, 1902), 5, 9, 558, 569–70. 8. Leake, Percival’s Medical Ethics, viii. 9. For example, Ivan Illich, Medical Nemesis: The Expropriation of Health (London: Calder and Boyars, 1975). 10. John V. Pickstone, ‘Thomas Percival and the Production of Medical Ethics’, in Baker, Porter, and Porter (eds), The Codification of Medical Morality, vol. 1, 161–78; Robert Baker, ‘Deciphering Percival’s Code’, in ibid. 179–211. 11. Vivian Nutton, ‘Beyond the Hippocratic Oath’, in Wear, Geyer-Kordesch, and French (eds), Doctors and Ethics, 10–37. 12. Roger French, ‘The Medical Ethics of Gabriele de Zerbi’, in Wear, Geyer-Kordesch, and French (eds), Doctors and Ethics, 72–97; Andrew Wear, ‘Medical Ethics in Early Modern England’, in ibid. 98–130; Roger French, ‘Ethics in the Eighteenth Century: Hoffmann in Halle’, in ibid. 153–180; David E. J. Linden, ‘Gabriele Zerbi’s De cautelis medicorum and the Tradition of Medical Prudence’, Bulletin of the History of Medicine, 73 (1) (Spring 1999), 19–37. 13. Iris Ritzmann, ‘Der Verhaltenskodex des “Savoir faire” als Deckmantel ärztlicher Hilflosigkeit’, Gesnerus, 56 (1999), 197–219. 14. John Harley Warner, ‘The 1880s Rebellion against the AMA Code of Ethics: “Scientific Democracy” and the Dissolution of Orthodoxy’, in Robert B. Baker, Arthur L. Caplan, Linda L. Emanuel, Stephen R. Latham (eds), The American Medical Ethics Revolution: How the AMA’s Code of Ethics Has Transformed Physicians’ Relationships to Patients, Professionals, and Society (Baltimore: Johns Hopkins University Press, 1999), 52–69. 15. Maehle, Doctors, Honour and the Law, 15–16. 16. Peter Bartrip, ‘An Introduction to Jukes Styrap’s Code of Medical Ethics (1878)’, in Baker (ed.), The Codification of Medical Morality, vol. 2, 45–148. See also Andrew A. G. Morrice, ‘ “Honour and Interests”: Medical Ethics and the British Medical Association’, in AndreasHolger Maehle and Johanna Geyer-Kordesch (eds), Historical and Philosophical Perspectives on Biomedical Ethics: From Paternalism to Autonomy? (Aldershot: Ashgate, 2002), 11–35. 17. Russell G. Smith, Medical Discipline: The Professional Conduct Jurisdiction of the General Medical Council, 1858–1990 (Oxford: Clarendon Press, 1994); Andreas-Holger Maehle, ‘Professional Ethics and Discipline: The Prussian Medical Courts of Honour, 1899–1920’, Medizinhistorisches Journal, 34 (1999), 309–38; Barbara Rabi, Ärztliche Ethik—Eine Frage der Ehre? Die Prozesse und Urteile der ärztlichen Ehrengerichtshöfe in Preußen und Sachsen 1918–1933 (Frankfurt/Main: Peter Lang, 2002). 18. Russell G. Smith, ‘Legal Precedent and Medical Ethics: Some Problems Encountered by the General Medical Council in Relying upon Precedent When Declaring Acceptable Standards of Professional Conduct’, in Baker (ed.), The Codification of Medical Morality, vol. 2, 205–18.

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19. Maehle, Doctors, Honour and the Law, 6–46, 123–4; Gerhard Vogt, Ärztliche Selbstverwaltung im Wandel. Eine historische Dokumentation am Beispiel der Ärztekammer Nordrhein (Cologne: Deutscher Ärzte-Verlag, 1998), 370. 20. Andrew A. G. Morrice, ‘ “Should the Doctor Tell?” Medical Secrecy in Early TwentiethCentury Britain’, in Steve Sturdy (ed.), Medicine, Health and the Public Sphere in Britain, 1600–2000 (London and New York: Routledge, 2002), 61–82; Andreas-Holger Maehle, ‘Protecting Patient Privacy or Serving Public Interests? Challenges to Medical Confidentiality in Imperial Germany’, Social History of Medicine, 16 (3) (2003), 383–401; Angus H. Ferguson. ‘Speaking Out about Staying Silent: An Historical Examination of Medico-legal Debates over the Boundaries of Medical Confidentiality’, in Imogen Goold and Catherine Kelly (eds), Lawyer’s Medicine: The Legislature, the Courts and Medical Practice, 1760–2000 (Oxford: Hart, 2009), 99–124. 21. Michael Stolberg, Homo patiens: Krankheits- und Körpererfahrung in der Frühen Neuzeit (Cologne: Böhlau, 2003); Jens Lachmund and Gunnar Stollberg, Patientenwelten: Krankheit und Medizin vom späten 18. bis zum frühen 20. Jahrhundert im Spiegel von Autobiographien (Opladen: Leske and Budrich, 1995); Roy Porter (ed.), Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial England (Cambridge: Cambridge University Press, 1985). 22. Sigrid Stöckel,Wiebke Lisner, and Gerlinde Rüve (eds), Das Medium Wissenschaftszeitschrift seit dem 19. Jahrhundert. Verwissenschaftlichung der Gesellschaft—Vergesellschaftung von Wissenschaft (Stuttgart: Franz Steiner Verlag, 2009). 23. Robert Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986); George J. Annas and Michael A. Grodin (eds), The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation (New York/Oxford: Oxford University Press, 1992); Volker Roelcke and Giovanni Maio (eds), Twentieth Century Ethics of Human Subjects Research: Historical Perspectives on Values, Practices, and Regulations (Stuttgart: Franz Steiner Verlag, 2004); Wolfgang U. Eckart (ed.), Man, Medicine and the State: The Human Body as an Object of Government Sponsored Medical Research in the 20th Century (Stuttgart: Franz Steiner Verlag, 2006). 24. Barbara Elkeles, Der moralische Diskurs über das medizinische Menschenexperiment im 19. Jahrhundert (Stuttgart: Gustav Fischer, 1996); Susan Lederer, Subjected to Science: Human Experimentation in America before the Second World War (Baltimore: Johns Hopkins University Press, 1995); Jonathan Moreno, Undue Risk: Secret State Experimentation on Humans (New York: Routledge, 2001); Paul M. McNeill, The Ethics and Politics of Human Experimentation (Cambridge: Cambridge University Press, 1993); Giovanni Maio, Ethik der Forschung am Menschen: Zur Begründung der Moral in ihrer historischen Bedingtheit (Stuttgart-Bad Cannstadt: Frommann-Holzboog, 2002); Paul J. Weindling, Nazi Medicine and the Nuremberg Trials: From Medical War Crimes to Informed Consent (Basingstoke: Palgrave Macmillan, 2004). 25. Roelcke and Maio (eds), Twentieth Century Ethics, and Eckart (ed.), Man, Medicine and the State; Ulrich Tröhler and Stella Reiter-Theil (eds), Ethics Codes in Medicine: Foundations and Achievements of Codification since 1947 (Aldershot: Ashgate, 1998); Jordan Goodman, Anthony McElligott, and Lara Marks (eds), Useful Bodies: Humans in the Service of Medical Science in the Twentieth Century (Baltimore and London: Johns Hopkins University Press, 2003); Ulf Schmidt and Andreas Frewer (eds), History and Theory of Human Experimentation: The Declaration of Helsinki and Modern Medical Ethics (Stuttgart: Franz Steiner Verlag, 2007).

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26. Barbara Elkeles, ‘The German Debate on Human Experimentation between 1880 and 1914’, in Roelcke and Maio (eds), Twentieth Century Ethics, 19–33; Ulrich Tröhler and AndreasHolger Maehle, ‘Anti-Vivisection in Nineteenth-Century Germany and Switzerland: Motives and Methods’, in Nicolaas A. Rupke (ed.), Vivisection in Historical Perspective (London/New York: Routledge, 1990), 149–87; Andreas-Holger Maehle, ‘The Ethical Discourse on Animal Experimentation, 1650–1900’, in Wear, Geyer-Kordesch, and French (eds), Doctors and Ethics, 203–51. 27. Elkeles, ‘The German Debate on Human Experimentation’, 27–8. 28. Christian Bonah and Philippe Menut, ‘BCG Vaccination around 1930—Dangerous Experiment or Established Prevention? Practices and Debates in France and Germany’, in Roelcke and Maio (eds), Twentieth Century Ethics, 111–27; Wolfgang U. Eckart and Andreas J. Reuland, ‘First Principles: Julius Moses and Medical Experimentation in the Late Weimar Republic’, in Eckart (ed.), Man, Medicine and the State, 35–47. 29. Paul Weindling, ‘From Medical War Crimes to Compensation: The Plight of the Victims of Human Experiments’, in Eckart (ed.), Man, Medicine and the State, 237–49. 30. Alexander Mitscherlich and Fred Mielke (eds), Medizin ohne Menschlichkeit: Dokumente des Nürnberger Ärzteprozesses (Frankfurt/Main and Hamburg: Fischer Bücherei, 1962); Volker Roelcke, ‘Human Subjects Research during the National Socialist Era, 1933–1945: Programs, Practices, and Motivations’, in Roelcke and Maio (eds), Twentieth Century Ethics, 151–66; Weindling, Nazi Medicine and the Nuremberg Trials. 31. Ulf Schmidt, ‘The Nuremberg Doctors’ Trial and the Nuremberg Code’, in Schmidt and Frewer (eds), History and Theory of Human Experimentation, 71–116. 32. Susan E. Lederer, ‘Research without Borders: The Origins of the Declaration of Helsinki’, in Schmidt and Frewer (eds), History and Theory of Human Experimentation, 145–164; Dominique Sprumont, Sara Girardin, and Trudo Lemmens, ‘The Helsinki Declaration and the Law: An International and Comparative Analysis’, ibid. 223–52. 33. Lederer, ‘Research without Borders’. 34. Robert Carlson, Kenneth Boyd, and David Webb, ‘The Interpretation of Codes of Medical Ethics: Some Lessons from the Fifth Revision of the Declaration of Helsinki’, in Schmidt and Frewer (eds), History and Theory of Human Experimentation, 187–202; David R. Willcox, ‘Medical Ethics and Public Perception: The Declaration of Helsinki and Its Revision in 2000’, in ibid. 203–21. 35. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects, http://www.wma.net/e/policy/b3.htm 36. James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, a Tragedy of Race and Medicine (New York: Free Press, 1993); Susan M. Reverby (ed.), Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study (Chapel Hill: University of North Carolina Press, 2000). 37. Paul J. Edelson, ‘Henry K. Beecher and Maurice Pappworth: Honor in the Development of the Ethics of Human Experimentation’, in Roelcke and Maio (eds), Twentieth Century Ethics, 219–33. 38. Ulrich Tröhler, ‘Human Research: From Ethos to Law, from National to International Regulations’, in Maehle and Geyer-Kordesch (eds), Historical and Philosophical Perspectives, 95–117. 39. Adam Hedgecoe, ‘ “A Form of Practical Machinery”: The Origins of Research Ethics Committees in the UK, 1967–1972’, Medical History, 53 (2009), 331–50. 40. Jenny Hazelgrove, ‘British Research Ethics after the Second World War: The Controversy at the British Postgraduate Medical School, Hammersmith Hospital’, in Roelcke and Maio (eds), Twentieth Century Ethics, 181–97.

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41. Weindling, ‘From Medical War Crimes to Compensation’; Andreas Frewer, ‘History of Medicine and Ethics in Conflict: Research on National Socialism as a Moral Problem’, in Schmidt and Frewer (eds), History and Theory of Human Experimentation, 255–74; Ulf Schmidt, ‘Medical Ethics and Human Experimentation at Porton Down: Informed Consent in Britain’s Biological and Chemical Warfare Experiments’, in ibid. 283–313. 42. Till Bärnighausen, ‘Barbaric Research—Japanese Human Experiments in Occupied China: Relevance; Alternatives; Ethics’, in Eckart (ed.), Man, Medicine, and the State, 167–96. 43. Volker Roelcke, ‘Die Sulfonamid-Experimente in nationalsozialistischen Konzentrationslagern: Eine kritische Neubewertung der epistemologischen und ethischen Dimension’, Medizinhistorisches Journal, 44 (2009), 42–60. 44. Pei P. Koay, ‘An Icelandic (Ad-)Venture: New Research? New Subjects? New Ethics?’, in Roelcke and Maio (eds), Twentieth Century Ethics, 335–48. 45. Sjef Gevers, Anke Janssen, and Roland Friele, ‘Consent Systems for Post Mortem Organ Donation in Europe’, European Journal for Health Law, 11 (2) (2004), 175–86. 46. David J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991). 47. Roger Cooter, ‘The Ethical Body’, in Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000), 451–68. 48. Albert R. Jonsen, A Short History of Medical Ethics (New York and Oxford: Oxford University Press, 2000), 99–114; idem, The Birth of Bioethics (New York and Oxford: Oxford University Press, 1998). 49. Gregory E. Pence, Classic Cases in Medical Ethics: Accounts of Cases That Have Shaped Medical Ethics, with Philosophical, Legal and Historical Backgrounds (Boston: McGrawHill, 2004), 333–35; Jonsen, A Short History, 104–6. 50. Jonsen, A Short History, 106–7; Thomas Schlich, Transplantation: Geschichte, Medizin, Ethik der Organverpflanzung (Munich: Beck, 1998); Robert M. Veatch, Transplantation Ethics (Washington, DC: Georgetown University Press, 2000). 51. Tony Hope, Julian Savulescu, and Judith Hendrick, Medical Ethics and Law (Edinburgh: Churchill Livingstone, 2003), 169–71. 52. Shaun D. Pattison, Medical Law and Ethics (London: Thomson Reuters, 2009), 450–83. 53. Pence, Classic Cases, 29–39; Jonsen, A Short History, 110–11. 54. Bryan Jennett, ‘Ethical Aspects of Life-Saving and Life-Sustaining Technologies’, in Maehle and Geyer-Kordesch (eds), Historical and Philosophical Perspectives, 119–37. On the history of the euthanasia movements in the United States and Britain, see Ian Dowbiggin, A Merciful End: The Euthanasia Movement in Modern America (Oxford: Oxford University Press, 2003); N. D. A. Kemp, Merciful Release: The History of the British Euthanasia Movement (Manchester: Manchester University Press, 2002). 55. Jonsen, A Short History, 109–10; Pence, Classic Cases, 127–29; Leslie J. Reagan, When Abortion was a Crime: Women, Medicine and the Law in the United States (Berkeley: University of California Press, 1997). 56. Pence, Classic Cases, 152–64. 57. Jane Maienschein, Whose View of Life? Embryos, Cloning and Stem Cells (Cambridge, MA, and London: Harvard University Press, 2003), 144–55. 58. Suzanne Holland, Karen Lebacqz, and Laurie Zoloth (eds), The Human Embryonic Stem Cell Debate: Science, Ethics and Public Policy (Cambridge, MA, and London: MIT Press, 2001); Nancy E. Snow, Stem Cell Research: New Frontiers in Science and Ethics (Notre Dame: University of Notre Dame Press, 2003); Wolfgang Bender, Christine Hauskeller, and Alexandra Manzei (eds), Grenzüberschreitungen—Crossing Borders: Cultural, Religious,

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and Political Differences Concerning Stem Cell Research: A Global Approach (Münster: Agenda Verlag, 2005). 59. Heinz-Gerhard Haupt and Jürgen Kocka (eds), Geschichte und Vergleich. Ansätze und Ergebnisse international vergleichender Geschichtsschreibung (Frankfurt/Main and New York: Campus Verlag, 1996), 37–9; Lutz Sauerteig, ‘Vergleich. Ein Königsweg auch für die Medizingeschichte? Methodologische Fragen komparativen Forschens’, in Norbert Paul and Thomas Schlich (eds), Medizingeschichte. Aufgaben, Probleme, Perspektiven (Frankfurt/ Main and New York: Campus Verlag, 1998), 266–91; Jürgen Kocka, ‘Comparison and Beyond’, History and Theory, 42 (2003), 39–44. 60. Recent examples are Heinz Schott, ‘Medizingeschichte und Ethik. Zum Gedenken an Rolf Winau’, Medizinhistorisches Journal, 43 (2008), 87–100; Martin S. Pernick, ‘Bioethics and History’, in Baker and McCullough (eds), Cambridge World History of Medical Ethics, 16–20.

Select Bibliography Annas, George J., and Michael A. Grodin (eds), The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation (New York and Oxford: Oxford University Press, 1992). Baker, Robert, Dorothy Porter, and Roy Porter (eds), The Codification of Medical Morality, vol. 1: Medical Ethics and Etiquette in the Eighteenth Century (Dordrecht: Kluwer Academic, 1993). —— (ed.), The Codification of Medical Morality, vol. 2: Anglo-American Medical Ethics and Medical Jurisprudence in the Nineteenth Century (Dordrecht: Kluwer Academic, 1995). —— , and Laurence B. McCullough (eds), The Cambridge World History of Medical Ethics (New York: Cambridge University Press, 2009). Cooter, Roger, ‘The Ethical Body’, in Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000), 451–68. Jonsen, Albert R., The Birth of Bioethics (New York and Oxford: Oxford University Press, 1998). Lederer, Susan, Subjected to Science: Human Experimentation in America before the Second World War (Baltimore: Johns Hopkins University Press, 1995). Maehle, Andreas-Holger, Doctors, Honour and the Law: Medical Ethics in Imperial Germany (Basingstoke: Palgrave Macmillan, 2009). Maienschein, Jane, Whose View of Life? Embryos, Cloning and Stem Cells (Cambridge, MA, and London: Harvard University Press, 2003). Roelcke, Volker, and Giovanni Maio (eds), Twentieth Century Ethics of Human Subjects Research: Historical Perspectives on Values Practices and Regulations (Stuttgart: Franz Steiner Verlag, 2004). Rothman, David J., Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991). Schmidt, Ulf, and Andreas Frewer (eds), History and Theory of Human Experimentation: The Declaration of Helsinki and Modern Medical Ethics (Stuttgart: Franz Steiner Verlag, 2007). Wear, Andrew, Johanna Geyer-Kordesch, and Roger French (eds), Doctors and Ethics: The Earlier Historical Setting of Professional Ethics (Amsterdam: Rodopi, 1993).

chapter 31

m edici n e a n d speci e s: on e m edici n e , on e history? robert g. w. k irk and m ichael worboys

‘Everywhere’, the critic and painter John Berger once observed, ‘animals disappear’.1 Berger argued that modernity, particularly its capitalistic and industrial forms, has reduced the number and diversity of animal species with which people interact. Where animals remain, as in the zoo, they do so only as a ‘monument to their own disappearance’.2 Yet, this absence has had the perverse effect of bringing the animal to the fore of contemporary intellectual thought and cultural concern. Thus, Roy Porter could write that ‘animals have become cerebrally and emotionally present, precisely because they are increasingly absent from our increasingly urbanized civilization’.3 Such a view resonates with the contemporary sense of ecological crisis, thereby promising the possibility of the kind of relevance and engagement that some have argued the history of medicine desperately requires.4 However, such promise is at best nascent. While some animals certainly have faded from everyday life, and some species have been characterized as on the precipice of extinction, many new ways to encounter animals have also emerged. Modernity has seen the practice of pet-keeping expand, opportunities for animal-related leisure activities and the number of animal-focused organizations increase, and the threat animals pose to human health become a global concern.5 In sum, a wealth of new types and sites for human interactions with animals developed with modernity. It should come as no surprise, then, that a growing body of philosophical, sociological, and historical literature has emerged focused on the study of human relations with non-human animals. Thematically, this literature tends to assume not only that interspecies relations have been sustained within modernity, but that they have been, and remain, fundamental to determining what it has meant to be human at any given historical moment. Such critiques of human exceptionalism do not, as some would have us believe, mark the historical rupture through which we proceed into a post-human future.6 On the contrary, they invite consideration of, and debate about, what it has been,

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and is, to be human in the modern world. Significantly, debates about interspecies relations are intrinsic to modern medicine; from fears of pandemics of cross-species viruses to the value of the animal model in laboratory investigations of human disease. Debates about interspecies relations occur foremost alongside those related to biomedical interventions in, and the consequent remaking of, the human and animal body. Consequently no group of scholars is better placed than historians of medicine to provide historical reference points and commentary on this subject. Yet in no body of scholarship is it more obvious, puzzling, and true to say that ‘animals disappear’. In 1993, Roy Porter noted that ‘historians of human medicine and historians of veterinary medicine seem to have relatively little contact with each other . . . in the academic world it is automatically assumed that a “historian of medicine” is a person who works in the history of human medicine’.7 This state of affairs, Porter argued, reflects the modern taken-for-granted separation of the human and the animal, and an assumption of human primacy. In the wake of subsequent ‘post-modern’ social, cultural, political, and academic critiques, the taken-for-granted human–animal dualism has become untenable. Thus, as long as Porter’s observation that medicine, for the history of medicine, is human medicine remains true, it follows that there are grounds to question the intellectual credibility, if not conceptual and cultural worth, of the field as it stands. In this chapter we survey the present position of the animal within the history of human medicine, linking this to work in the history of veterinary medicine, and we speculate on the value of making ‘species’ a central and unifying theme of a new history of medicine. We argue that re-conceiving medicine as a set of knowledge-practices grounded in interspecies interactions promises to reinvigorate the subject. We draw on a diverse theoretical literature ranging from ‘animal studies’ to ‘post-human’ literature in order to suggest how such an approach could allow us to re-imagine what medicine has been and still may be. This is a timely project as the medical and veterinary professions, after long debating the notion of ‘one medicine’ as ‘a common pool of knowledge in microbiology, immunology, physiology, pathology and epidemiology’, are now calling for action and institution building to develop the field.8 We argue that our field should become the history of one medicine by recognizing the complex interactions between species that have been present throughout history.

Animals and ancients It is curious that the history of human disease is conventionally linked to the domestication of animals, beginning some 10,000 years ago, yet Western historians often assume medicine to be only 2,000 to 3,000 years old, originating in the Hippocratic corpus of ancient Greece. This is, of course, in large part due to differing historiographic methodologies, epistemological approaches, and categorical definitions of what medicine was and is. An absence of textual evidence from civilizations prior to the Greeks has also encouraged historians to ignore earlier practices. Thus, historians of

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medicine have tended to dismiss Egyptian medicine, for example, on the grounds that no evidence survives to suggest an influence on Greek ideas.9 Yet those scholars who have examined Egypt report a vibrant medical culture which they suggest grew from a concern for animal, as much as human, health. Egyptian medicine, it has been argued, emerged from attempts to preserve the health of large animals due to their religious and economic value within a predominant ‘cattle culture’, producing practices that were subsequently applied to humans.10 This thesis narrows the distance between our explanations of the origins of disease and medicine. Be this as it may, we know that animal medicine was practised in ancient Greece, with particular focus on the culturally valued horse. Classical scholars tend to agree that this early veterinary medicine was ‘primarily a matter of empirical practice, never reaching any level comparable to that of Aristotelian zoology or human medicine of the Hippocratic school’.11 The poverty of historical imagination deriving from this circular definition of medicine is clear, as are the limitations to historical study so produced. In the Hippocratic tradition, knowledge of the anatomy and function of the human body could be gained from observing both the human and animal. Observing, that is, without intervening. It was Aristotle who materialized the human–animal analogy, first reconceptualizing man as comparable to other animals before dissecting numerous types of animal, as well as aborted human foetuses. He did not, however, study human cadavers nor practise vivisection. Aristotle’s departure from Platonic anthropocentricism not only provided the conditions of possibility for intervening with the animal body in order to build knowledge about the human, but necessitated the re-inscription of the human–animal boundary via the principle that man alone possessed a rational mind. The Aristotelian distinction between life and death inspired the medical school of Alexandria to controversially extend dissection to live animals in the fourth and third centuries BCE.12 Followers of Hippocrates, in contrast, objected to the deliberate infliction of wounds for the pursuit of knowledge, holding to the conviction that the physician must do no harm to humans or, significantly, to animals.13 Nevertheless, the medical school at Alexandria became the leading centre for vivisection in the ancient world, renowned for the work of the physician Herophilus, who, dissatisfied by analogy, vivisected human beings to observe organs in their natural state. The breaking of taboos against the opening of the human body, however, was exceptional and much of what was understood about human anatomy and physiology continued to be drawn from the animal body.14 As is well established, Galen made a virtue of his limited access to human bodies by privileging the animal as a site for knowledge production through observation and, importantly, experiment. In the medieval and early Renaissance period Galen’s work was canonical, although his advocacy of experiment was all but lost as dissection was expected to illustrate established knowledge rather than question or build upon it. When human dissection was again practised in the fourteenth and fifteenth centuries, anatomists re-inscribed Galenic features of the animal body in constructing knowledge of human anatomy. Historians have tended to interpret the persistence of animal over human descriptions at this time as a ‘failure’ to recognize where the human cadaver departed from established textual authorities.15 This is fine as

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far as it goes, but when compared with the more nuanced approach of those historians who have begun to take the use of animals critically, such explanations begin to look inadequate.

Anatomy and humours Historians have already moved to discuss Renaissance anatomy as a site where human materiality was produced from disparate forms of knowledge and practice, textual and biological, within which the always unstable species boundary was traversed and redefined; that is, dissection and vivisection were used to constitute the human body by combining human and animal.16 Anatomy, on this reading, becomes a site where the being of being human was ‘made up’, but not necessarily through articulations of animal–human difference. Such an analysis could be applied through the sixteenth to eighteenth centuries, for example, from Harvey’s work on the circulation of the blood, through to the work of William (1718–83) and John Hunter (1728–93) on comparative anatomy.17 With this approach, historical understandings of medicine would better reflect and inform recent scholarship that asserts that ‘a key aspect of being human in the early modern period involved animals’.18 While this seems to work well for anatomy, what relevance might it have for medical practice? Addressing this question moves us toward material practices where human and animal health were understood to be analogous.19 When animals were described with humoral traits in early modern England this was not vulgar anthropomorphism, but a result of the fact that both human and animal were understood to share humoral corporality.20 It is hardly a wild inference, then, to suggest that animals may have contributed to the construction of humoral theory as well as being understood through it. Similarly, while disease ecology might rightly be considered a twentieth-century form of knowledge, the cultural history of disease interactions of animals and humans is both long and largely unexplored. For example, the term ‘distemper’ was used widely for human ailments, almost as a synonym of disease. Yet it had equal, if not greater, currency in animals where it persisted longer as a catch-all for systemic ailments before being specified as viral disease in the twentieth century.21 While we await historical answers to our speculation, we can be sure that animals and animal medicine had a place in the early modern ‘medical marketplace’. Indeed, there were a plurality of options for the treatment of sick animals by the seventeenth century, ranging from the proto-professional, army-based elite who mainly dealt with horses, to specialist farriers, horse leechers (often surgeons), general leechers, and laymen who treated a wide variety of animals. Practice would have been similar to bedside medicine with the exception that only valued animals, economic or sentimental, would have been treated, others being killed. Diagnosis would have relied on the owner’s narrative, and although physical examination would have been possible bodily signs were difficult to read. Treatments were heroic, which would have impressed owners and been in line with

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the regimens of human medicine: purging, bleeding, drugging, and dietary. Thus, Louise Hill Curth has argued that historians must abandon the assumption that the history of animal medicine is that of the veterinary profession and recognize the shared features of human and animal healing.22 There was, perhaps, even greater commonality with surgery, given the lower status of surgeons and the similarities in skin afflictions and injuries of humans and animals. The boundaries between human and animal medicine are known to have been porous in the early modern period, particularly in rural environments, though scholarship on this topic remains slight.23 Given that medical men showed interest in, and wrote on, animal disease, and that the management of health and disease extends beyond the professions in any age, it seems obvious that historians should be sensitive to the place of interspecies interactions in the development of all aspects of medicine.

Bedside and ‘stall-side’ medicine The formal professional separation of human and animal medicine began around 1800 with the development of a single human medical profession and the emergence of the hospital as the site of medical training and knowledge production. Medical ‘professionalism’ was in large part driven by rank-and-file practitioners whose attempts to level up involved distancing themselves, not only from the ‘alternative’ practitioners about whom historians have written extensively, but also those who practised across the human– animal boundary. Historians have placed great emphasis on the role of the hospital in the development of modern human medical practice and knowledge. Key changes in practice were the development of the consultant role, collective teaching, physical examination of the sick, access to bodies for post-mortem investigations, the collection of statistics, and opportunities to observe the natural history of disease. With medical knowledge, humoralism was replaced by lesion-based pathology where changes in tissues, often only identified post-mortem, were correlated to symptoms in the sick, which doctors used to differentiate and specify more types of disease. Overall, these changes saw a switch to medical knowledge focused on localized lesions, beginning the alleged ‘disappearance of the sick man’ from modern medicine.24 At the same time, the hospital became the preferred place of education, with students taught medicine and surgery as a collective experience. Animal medicine did not experience the same ‘hospital revolution’ or professional reform; most veterinarians continued to practise, in yards or in stables, what might be termed ‘stall-side’ medicine. Across Europe, there were few animal hospitals and veterinary colleges were small in number and mainly offered training for military service. The emergence of an organized veterinary profession came later, emulating human medicine rather than developing with its own dynamic.25 Elite veterinarians were within, or closely associated with, the military; thus veterinary colleges were military-style institutions where training was

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dominated by the horse. This expertise readily transferred to the civilian sphere to service the needs of the wealthy, who bred, rode, and raced equines, and those who worked horses in transport, agriculture, and industry. There was little demand for treatment of ‘animals of the farm’, apart from prize breed stock, as sick beasts tended to be promptly slaughtered to realize their economic value or prevent the spread of disease. However, the innovations of hospital medicine were gradually adopted in veterinary colleges, with new nosologies, diagnostic technologies, and lesion-based pathology figuring in veterinary textbooks. The specificities of how, when, and with what adaptations this occurred have still to be determined and it needs to be asked whether the flow of knowledge was one-way. While the development of hospital medicine was a key factor in the creation of two medicines, there were countervailing forces that can be productively explored through the lens of one medicine, a most obvious point of departure being public health. The public health movement had an environmentalist conception of the determinants of health; hence, it recognized the importance of man’s relationships with animals.26 In its critique of urban conditions and working-class lifestyles, the movement’s condemnation of the persistence of pig-keeping, the stench from dairies, and the threat of cur dogs made the governance of interspecies interaction a key problematic. Yet paradoxically, public health discourse equally recognized that in rural areas, where people lived in much greater proximity to animals within equal squalor, there was a significant mortality advantage.27 While public health made urban animals a classic case of pollution,‘matter out of place’, as well as exemplifying the sanitarian idea that smell equalled disease, there were alternative views: the urban working classes, for example, understood pigs to be recyclers of waste, helping to keep water clean while providing essential meat to strengthen human bodies. Dogs, too, were seen to be an important means of vermin control.28 A remarkable feature of the rise of hospital medicine is the fact that from the end of the seventeenth through to the mid-nineteenth century the use of leeches as a form of bloodletting reached its height. The practice of leeching is an example par excellence of a medical practice grounded in interspecies interaction. While the use of the leech as a clinical tool in this period has yet to be rigorously explored by historians, the terrain is rich. The social, cultural, and political infrastructure that sustained the leeching practice was diverse and its effects widespread. These included the near extinction of the Hirudo medicinalis in England due to over-harvesting, the growth of an international leech trade, the emergence of new expertise about the proper care and management of leeches themselves, and the development of a plethora of material technologies for the breeding, storage, transportation, and clinical use of medicinal leeches.29 Indeed, the leech was so important to medicine in the first half of the nineteenth century that at least one contemporary understood the rise of laboratory medicine towards its end to indicate that the ‘leech is no longer in fashion and the favour of mankind has passed to the mammalian’.30 The leech, of course, was far from the only site of medical interspecies interaction. Most famously Edward Jenner’s development of vaccination depended upon the cow. Hitherto, historians have all but ignored the practices that developed

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around infecting calves and harvesting their serum, processes adapted and industrialized to great effect in the pharmaceutical industry of the early twentieth century. Nor have they had much to say about cowpox itself, seeing it rather benignly only in terms of Jenner’s development of vaccination for smallpox.

Animals in the laboratory A partial, and little explored, consequence of the disappearance of the ‘sick man’ in nineteenth-century medicine was his replacement by other species with the rise of laboratory science.31 In the new scientific medicine, species as diverse as the frog and dog became the source of physiological knowledge, while the guinea-pig, mouse, and rat, amongst countless others, came to serve as experimental tools and materials for research and routine diagnoses. From the 1860s, laboratory investigations increasingly became a source of medical knowledge, with key innovations made by scientists working in academic, and latterly industrial, settings as well as the hospital.32 In this new research, nonhuman animals became used as human proxies on the assumption that processes such as respiration, nutrition, and excretion were analogous with those in human bodies. This analogy, as much as the material practices of the laboratory, reconstituted what it was to be human or animal, most famously in the nineteenth-century vivisection debates where the capacity of animals to suffer pain instigated critical reconfigurations of human–animal relations that continue to shape the way we think of ourselves today. Anti-vivisectionists attempted, with some success, to make practices of interspecies interaction a core and contested site upon which human identity, moral nature, and trust of medical men and medical knowledge rested.33 Nevertheless, studies of animal bodies continued to shape the construction of knowledge of human physiology as well as medical practice. In studying the development, organization, techniques, replication, and productivity of the biological sciences at the level of material practice, historians of science have made the agency of laboratory animals a key focus of scholarship.34 A major theme is the extent to which a specific species, often initially chosen for contingent reasons, served to shape whole research communities, from the social relations and material practices of the laboratory to the knowledge claims produced.35 Historians of medicine have been slow to follow these approaches, but there is much potential, for example, in the work of Claude Bernard (1813–78). As the pre-eminent new experimental physiologist, he was dependent upon complex and innovative interspecies interactions outlined in his influential An Introduction to the Study of Experimental Medicine (1865).36 Bynum has noted that Bernard’s success came not from ‘sophisticated laboratory apparatus’ but ‘superb operative technique [with animals and] his capacity to keep experimental animals alive through the follow-up’, a suggestive observation that has not been pursued.37 Work on Bernard’s first major discovery, the role of liver in glycogen synthesis, depended on obtaining samples of blood from the veins and arteries of animals (anaesthetized and not), the surgical removal of the liver, the puncturing of the brain of

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dogs, the electrical stimulation and severing of their nerves, and numerous feeding experiments.38 However, in the historical analyses of Bernard’s work, the ‘animal disappears’ in at least two significant ways. First, the animal is atomized, becoming the ‘liver’, ‘blood’, or a range of physiological variables. Such unproblematic reductionism would have troubled even Bernard, who, as Canguilhem argued, regularly wavered on the adequacy of such knowledge.39 Second, there is no analysis of how the particular species chosen by Bernard influenced the medical knowledge he produced. A telling example is how the recognition of ‘emotional hyperglycaemia’ developed from the observation that blood sugar levels rose in poorly anaesthetized dogs. If this work had been undertaken on rats, say, would investigators have ever thought about ‘emotional’ states? If in physiology non-human animals came to be both subject and object of research, with the advent of bacteriology from the 1880s the relation between animal and human medicine was made significantly more complex. The use of animal models for human diseases, particularly in the work of Robert Koch (1843–1910) and his followers, whose famous ‘postulates’ depended on finding susceptible animals in which the disease could be reproduced, began the process of translating the nonhuman animal from subject to tool of research.40 Establishing animal models of human diseases in some cases proved relatively easy as with tuberculosis in guineapigs, but other diseases, including cholera, gonorrhoea, and leprosy, proved more elusive. Though practically problematic, these difficulties were theoretically expected, as the Koch School worked within the assumption that diseases were specific; that is, particular bacteria produced distinct diseases that could be unique to individual species. At the same time, bacteriological research depended on diseases transcending species barriers, which meant that human and animal medical discourses remained grounded in shared knowledges and practices. This interdependence went beyond research. The production, testing, and standardization of new therapeutics also depended upon a series of interspecies interactions, ranging from the horse to the guinea-pig to the human.41 Louis Pasteur (1822–95) also made biomedical experiment and therapeutic development a matter of interspecies interaction.42 His development of protective vaccines depended on the modification of the virulence of micro-organisms by repeated inoculations through different animals. Pasteur drew parallels between his artificial process and ‘natural’ variations in microbial virulence. His methods relied on the differential susceptibility of different animal species to different infections, allowing immune products to be experimentally produced in non-susceptible animals. The most celebrated application of these methods was the development of rabies vaccine, which saved the lives of people bitten by rabid dogs who had previously faced an agonizing death with mind and body out of control. The vaccine, which took advantage of the long incubation period so as to be therapeutic rather than preventive, was produced in rabbits, tested on dogs, and used clinically with humans.43 Arguably, this was the first ‘medical breakthrough’ of the modern era, inventing the genre, and was used by the medical profession to bring the value of vivisection and, by implication, the dependence of modern medicine upon interspecies interaction to the wider public.44

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The commercialization of vaccines, antisera, and antitoxins led to the industrialization of laboratory practices.45 Infecting animals, harvesting their blood or organs, processing to make materials suitable for inoculation into humans, standardizing therapeutic potency (through observation of effects on groups of small animals typically mice, rats, or rabbits), and calculating effective and safe dosages (again on groups of animals) before giving controlled doses to humans has yet to be fully examined by historians as a series of interspecies interactions. Furthermore, the extensive use of animals in laboratories was not only a European development; researchers in India adapted the local fauna to produce new sources for vaccine and serum development.46 Indeed, histories of medicine and empire offer a rich setting for inclusively considering the nonhuman animal, particularly with reference to vector-borne disease transmission, as with malaria and sleeping sickness.47 Bacteriology was a major stimulus to the growth of laboratory research from the late nineteenth century, creating an ontological and epistemological dependence upon animals that Bynum ascribed to germ theories having ‘linked human medicine inextricably with animals’.48 Bynum is one of the few historians of medicine sensitive to the material turn that brought the laboratory organism to centre stage in historical and sociological studies of laboratory science. He presented historians of medicine with four questions: what was the source of experimental animals; what is the historical relationship between the development of animal models and disease specificity; what were the techniques of animal experiment; and, finally, what was the intellectual framework that justified the animal–human analogy?49 Historians of modern medicine have all but ignored Bynum’s programmatic article; only where animal experiment touched upon social history, as in anti-vivisection, has the topic been addressed and even then with little or no interest in how these issues shaped knowledge and practice within the laboratory.50 In contrast, we would argue that by drawing upon animal studies historians would do well to emphasize the interdependence, co-emergence, and co-constitution of material practice, knowledge, and social organization within medicine. The late nineteenth and early twentieth centuries witnessed the discovery of a host of new biological substances, including vitamins, hormones, and most famously insulin, all of which depended upon animals as source, mode of understanding, mode of production, and standardization in an analogous yet contextually different way to that of vaccines.51 Biologicals instigated the beginning of a transformation in medical knowledge and practice, which saw interspecies interaction, and the non-human animal, confirmed as obligatory passage points within medical science. Paul Ehrlich’s development of protocols whereby small animals were used to standardize therapeutics derived from the newly discovered ‘biologicals’, which included vitamins and hormones, made clinical interventions routinely dependent upon the use of small animals to establish safe and efficacious doses. Through the first half of the twentieth century dependence upon interspecies interaction was institutionalized, not least by Sir Henry Dale (1875–1968), who sought, in addition to protecting the patient, to provide for the emerging pharmaceutical industry’s need for international trade within a medico-legal framework.52 The centrality and consequent importance of the animal in the reconfiguration of

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disciplinary and industrial knowledges, practices, and institutions is evident in the struggle of the British Wellcome Physiological Laboratories to become registered under the Cruelty to Animals Act (1876) between 1894 and 1904.53 The exponential rise in animal use recorded under this legislation from a meagre 270 in 1879 to 958,761 by 1939 testifies to the growing importance of the animal in biomedical practice.54 New therapeutics were, of course, far from the only area of scientific medicine functioning as a site dependent upon interspecies interaction. Animals became routinely used as reagents in medical science, most famously in pregnancy testing but also for diagnosing infectious diseases such as tuberculosis. These new medical procedures required hospitals to maintain a laboratory and animal house to undertake routine diagnostic tests, suggesting that the analysis of the role of the non-human animal in the hospital would be productive. Animals were also essential to the LD (lethal dose) test used in toxicology, which estimated the relative potency of drugs and other substances, including biological and chemical substances, in terms of the concentration required to kill a specified percentage of a test population of animals. Thus, LD01 was the lethal dose for 1 of a test population, while LD50, the most commonly used measure, killed half the test population. The test was developed by J. W. Trevan (1887–1956) at the Wellcome Physiological Research Laboratories in 1927 in work on bacterial toxins and tests on rabbits, which he extended to the use of statistical methods that required large numbers of animals, in one case 27,000 mice.55 One consequence of the use of animals in routine procedures such as the LD50 was that conventionally distinct sites such as the laboratory, clinic, farm, zoo, and slaughterhouse became situated in relation to one another within a network of knowledge transfer and bodily supply that has yet to be subject to rigorous historical analysis.56 Another was that basic knowledge of animal health became a requirement for those working in purportedly human medical science, further illustrating how human and animal medicines were interdependent.57 From the breeding and husbandry of animals, to their use in experiment and production, to the exchange of bodily fluids across species in regimes of vaccination and diagnostic testing, medical knowledge and practice through the twentieth century can be seen to have been historically situated examples of conceptual and material, metaphorical and literal, interspecies interactions.

Conclusion: one medicine, one history? At the turn of the nineteenth into the twentieth century, leading voices across human and animal medicine believed that it was ‘no longer possible to recognize two entirely distinct branches of medicine . . . Comparative medicine is the medicine of the future, and the sooner that is realized, the better for man and beast.’58 No less a name than Sir William Osler (1849–1919) believed human and veterinary medicine to be interdependent, demonstrable, for example, in comparative pathology, reconfigured from the study of morbid anatomy to that of the anatomy of disease.59 Yet historical scholarship has little to say about the interdependence, let alone union, of human and animal medicine.

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It is generally presumed that the ideal of a unified medicine struggled to establish itself, for reasons yet to be fully understood, and was subsumed by the use of animals to ‘model’ human diseases. Even so, strikingly little research has addressed the history of the animal as a model for human infectious diseases; historical attention has instead focused upon the cancers and the struggle to establish a continuum between bench and bedside.60 Here again, particularly in the late twentieth century, medicine is evidently a site of interspecies interaction, whether in the case of human cancers being grafted upon immunologically comprised (so-called ‘nude’) mice, the human creation of cancerprone organisms such as Oncomouse, or the development of transgenic animals.61 Nevertheless, by the late twentieth century human and animal medicine, in terms of discipline, profession, and institutions, are in the main assumed to be independent from one another. Within the laboratory, for example, the health and welfare of animals has been delegated to animal technicians under the guidance of veterinary expertise, leaving biomedical research scientists to pursue their object of study often at a molecular level that transcends any notion of species. It might well be argued that twentiethcentury animal medicine developed more as a handmaiden to the pursuit of human medicine than for the needs of the animals in themselves. Woods has persuasively argued that the veterinary profession, at least in Britain, traditionally showed comparatively little interest in pursuing scientific research into animal health, preferring quarantine and slaughter as a means of controlling foot and mouth disease.62 That said, veterinarians have been quick to adopt the conceptual and material practices of human medicine at other times, not least in defending their expertise and right to govern the use of antibiotics in late-twentieth-century agricultural production.63 In part, perhaps, the disappearance of the animal in medical history has been caused by an artificial fracturing of the histories of science, technology, and medicine within academic disciplinary politics. Though widely recognized, this fracturing is rarely problematized. Re-imagining medical practice as situated interspecies encounters reveals the distinction between historians of medicine, science, and technology as both a difficult and pedantic one to make, with few benefits and many drawbacks. Critical thought in the wider academy, of which animal studies is a part, has moved toward a language of emergence, relationship, interpenetrative coexistence, co-constitution, and integrative mutuality, which is increasingly reflected within the history of science but less so in that of medicine.64 Such a language, we argue, provides a platform for the re-thinking, if not re-radicalizing, of medical history as a critical and productive voice within and without the academy, capable of reconstituting the histories of animal and human medicine, if not the fields of science, technology, and medicine, as ‘one history’ in the process. History demonstrates that public consciousness has long been capable of imagining a plurality of interconnections between human and animal health, disease, and medicine. At the time of writing, when food has moved from sustaining to threatening our health, with its sites of production increasingly seen as reservoirs of disease produced through ill-considered use of medical technologies such as antibiotics, hard distinctions between human and animal medicine have again begun to be seen as doing more harm than good. In recent decades the British veterinary profession has had some success in

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establishing animal health as a research field with direct implications upon human health as part of a wider agenda to build a profile for veterinary research comparable to that of the human medicine. For example, on his retirement as Principal of the Royal Veterinary College in 1989, Alan Betts, arguably one of the most research-minded of twentieth-century British veterinarians, became involved in the establishment of the Comparative Clinical Science Foundation, intended to ‘reunite’ human and animal medicine. Appropriately, the day after Betts’ death in 2005, the British Medical Journal and the Veterinary Record published unprecedented joint editions grounded in the ethos of ‘one world, one medicine’. Despite there being few funding bodies with remits wide enough to support research into human and animal health, the British Wellcome Trust and American Rockefeller Foundation being notable exceptions, the ideal of a united medicine has nevertheless been reborn in the twenty-first century under the titles ‘one medicine’ and ‘one health’. History has played a role in these developments.65 Hitherto, historians of medicine have not. There are, of course, numerous other sites that we could have addressed in advancing our argument. We could have discussed the early investigations of Robert Boyle (1627–91) and Richard Lower (1631–91) at the Royal Society in the mid-1660s where blood was transfused from animal to human. More than a mere material, biological, transaction, the intent was to alter the personality of the patient by giving the blood of a docile sheep to a twenty-two-year-old Cambridge student whose manic brain was thought ‘a little too warm’.66 Here we see not only another example, albeit short lived, of medicine as interspecies interaction, but also the extent to which the material and mental interiority of human and animal were interdependent. Similar themes emerge in the practice of skin grafting and organ transplantation in the nineteenth and twentieth centuries as well as later debates over xenotransplantation, while the development of animal behavioural studies, through comparative psychology, behaviourism, and ethology, demonstrates the same.67 Here, we have merely gestured towards possible future routes for the history of medicine, albeit ones we would wish to see realized. By exploring how medical knowledge and medical practice have been informed and formed by categories of class, race, and gender, the history of medicine opened up new territories of thought, making possible new interventions into the understanding and development of the medical discourses. At the time of writing, critical and cultural theorists have extended their interest in the ‘other’ to encompass species, asking, for example, to what extent our cultural discourses are mediated by anthropocentrism and human exceptionalism.68 This question, itself a product of the biomedical and biopolitical world in which we are situated, is one that should occupy historians of medicine. Just as a prior generation of scholars revealed the extent to which medical discourses have been gendered, we now should question the extent to which these same discourses are also specied. We suggest that one approach would be to think of medicine as a site where situated encounters between species occur, though we admit such an agenda raises difficulties of analytic terminology. An escape from essentialist and exceptionalist conceptualizations of the human cannot be made by essentializing or exceptionalizing the animal nor the category of species. Difference as much as essence is contingent, only

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properly comprehended through the resource of historical context. What we call interspecies interactions, therefore, should not be understood to assume difference to be transcendent of history. On the contrary, we see difference always to be a product of history. We remind the reader this is not a controversial stance. On the one hand, contemporary biology acknowledges the fact that species are subject to historical (evolutionary) change. On the other, historical research has repeatedly demonstrated what more broadminded biologists have always accepted: categories of species demarcation have been purposefully constructed and as such change along with that purpose. Our use of interspecies interaction is intended to convey the process by which notions of difference and essence are co-constituted in historically situated encounters. We have implicitly drawn upon Donna Haraway’s notion of ‘situated histories, situated nature-cultures, in which all the actors become who they are in the dance of relating, not from scratch, not ex nihilo, but full of the patterns of their sometimes-joined, sometimes-separate heritages both before and lateral to this encounter’, in order to argue that medicine can be seen to be a pre-eminent site where such processes have taken and take place.69 Only by approaching the study of medicine from this perspective can we properly understand medicine’s role in making up who we have been, are, and are yet to be. We invite historians of medicine, as well as those of science and technology, to join the dance, and recognize that in doing so the dancers can be remade, perhaps, as one.

Notes 1. John Berger, ‘Why Look at Animals?’, in About Looking (New York: Vintage, 1980), 24; and a critique in Jonathan Burt, ‘John Berger’s ‘Why Look at Animals?’ A Close Reading’, Worldviews, 9 (2005), 202–18. 2. Ibid. 24. 3. Roy Porter,‘Man, Animals and Medicine at the Time of the Founding of the Royal Veterinary College’, in A. R. Mitchell (ed.), History of the Healing Professions: Parallels between Veterinary and Medical History (Wallingford: CAB International, 1993), 19–30, 20. 4. Roger Cooter, ‘After Death/After-“Life”: The Social History of Medicine in PostPostmodernity’, Social History of Medicine, 20 (2007), 441–64. 5. Adrian Franklin, Animals and Modern Cultures: A Sociology of Human–Animal Relations in Modernity (London: Sage, 1999). 6. Matthew Calarco and Peter Atterton (eds), Animal Philosophy: Essential Readings in Continental Thought (London: Continuum, 2004). 7. Porter, ‘Man, Animals and Medicine’, 19. 8. G. Easton and M. Alder, ‘One Medicine?’, British Medical Journal, 331 (2005), 7527. 9. V. Nutton, ‘Healers in the Medical Market Place: Towards a Social History of GraecoRoman Medicine’, in Andrew Wear (ed.), Medicine and Society (Cambridge: Cambridge University Press, 1992), 15–58, at 32. 10. Andrew Hunt Gordon and Calvin W. Schwabe, The Quick and the Dead: Biomedical Theory in Ancient Egypt (Leiden: Brill, 2004); Andrew H. Gordon, ‘The Observation and Use of Animals in the Development of Scientific Thought in the Ancient World with

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11. 12.

13. 14. 15.

16.

17.

18.

19. 20. 21. 22. 23. 24. 25.

26.

robert g. w. kirk and michael worboys Especial Reference to Egypt’, in Linda Kalof (ed.), A Cultural History of Animals in Antiquity (Oxford and New York: Berg, 2007), 127–50. Liliane Bodson, ‘Veterinary Medicine’, in S. Hornblower and A. Spawforth (eds), The Oxford Classical Dictionary, 3rd edn (Oxford: Oxford University Press, 1996), 1592–3, at 1592. Ludwig Edelstein, ‘The History of Anatomy in Antiquity’, in Owsei Temkin and C. Lilian Tempkin (eds), Ancient Medicine: Selected Papers of Ludwig Edelstein (Baltimore: Johns Hopkins University Press, 1967), 247–301. Wesley D. Smith, The Hippocratic Tradition (Ithaca: Cornell University, 1979). Heinrich von Staden, Herophilus (Cambridge: Cambridge University Press, 1989), 139–53. Nancy G. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago: University of Chicago Press, 1990); Roger French, Dissection and Vivisection in the European Renaissance (Farnham: Ashgate, 1999). Andrew Cunningham, The Anatomist Anatomis’d: An Experimental Discipline in Enlightenment Europe (Farnham: Ashgate, 2009); Andreas-Holger Maehle and Ulrich Tröhler, ‘Animal Experimentation from Antiquity to the End of the Eighteenth Century: Attitudes and Arguments’, in Nicolas A. Rupke (ed.), Vivisection in Historical Perspective (London: Routledge, 1990), 14–47. R. French, William Harvey’s Natural Philosophy (Cambridge: Cambridge University Press, 1994); Simon Chaplin, ‘Nature Dissected, or Dissection Naturalized? The Case of John Hunter’s Museum’, Museum and Society, 6 (2008), 135–51; W. D. Ian Rolfe, ‘William and John Hunter: Breaking the Great Chain of Being’, in W. F. Bynum and Roy Porter (eds), William Hunter and the Eighteenth-Century Medical World (Cambridge: Cambridge University Press, 1985), 298–322. Erica Fudge, Brutal Reasoning: Animals, Rationality and Humanity in Early Modern England (Ithaca: Cornell University Press, 2006), 178; Angela N. H. Creager and William Chester Jorden (eds), The Animal/Human Boundary (Rochester: University of Rochester Press, 2002); Erica Fudge, Perceiving Animals: Human and Beasts in Early Modern English Culture (Urbana/Chicago: University of Illinois Press, 2002); Erica Fudge, Ruth Gilbert, and Susan Wiseman (eds), At the Borders of the Human: Beasts, Bodies and Natural Philosophy in the Early Modern Period (Basingstoke: Palgrave, 2002). Lise Wilkinson, Animals and Disease: An Introduction to the History of Comparative Medicine (Cambridge: Cambridge University Press, 1992), 1–15. Gail Kern Paster, Humoring the Body: Emotions and the Shakespearean Stage (Chicago: University of Chicago Press, 2004). Leon F. Whitney and George D. Whitney, The Distemper Complex (Jersey, NJ: T. F. H. Publications, 1953), 1–6. Louise Hill Curth, The Care of Brute Beasts: A Social and Cultural Study of Veterinary Medicine in Early Modern England (Leiden: Brill, 2009). Caroline C. Hannaway, ‘Veterinary Medicine and Rural Health Care in Pre-Revolutionary France’, Bulletin of the History of Medicine, 51, (1977), 431–47. N. D. Jewson, ‘The Disappearance of the Sick-Man From Medical Cosmology’, Sociology, 10 (1976), 224–44. Abigail Woods and Stephen Matthews, ‘ “Little, If at All, Removed from the Illiterate Farrier or Cow-Leech”: The English Veterinary Surgeon, c.1860–1885, and the Campaign for Veterinary Reform’, Medical History, 54 (2010), 29–54. Anne Hardy, ‘Animals, Disease, and Man: Making Connections’, Perspectives in Biology and Medicine, 46 (2003), 200–15.

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27. John M. Eyler, Victorian Social Medicine: The Ideas and Methods of William Farr (Baltimore: Johns Hopkins University Press, 1979). 28. Christopher Hamlin, Public Health and Social Justice in the Age of Chadwick (Cambridge: Cambridge University Press, 1998); Michael Sigsworth and Michael Worboys, ‘The Public’s View of Public Health in Mid-Victorian Britain’, Urban History, 21 (1994), 237–50. 29. Robert G. W. Kirk and Neil Pemberton, Leech (London: Reaktion Books, forthcoming). 30. ‘Special Correspondence: Paris: The Animals of Medicine’, British Medical Journal, 2 (23 September 1911), 708. 31. Andrew Cunningham and Perry Williams (eds), The Laboratory Revolution in Medicine (Cambridge: Cambridge University Press, 1992). 32. E. M. Tansey, ‘ “The Queen Has Been Dreadfully Shocked”: Aspects of Teaching Experimental Physiology Using Animals in Britain, 1876–1986’, American Journal of Physiology Education, 19 (1998), S18–33. 33. Richard. D. French, Antivivisection and Medical Science in Victorian Society (Princeton: Princeton University Press, 1975); A. Guerrini, Experimenting with Humans and Animals: From Galen to Animal Rights (Baltimore: Johns Hopkins University Press, 2003). 34. A. E. Clarke and J. H. Fujimura, The Right Tools for the Job: At Work in the TwentiethCentury Life Sciences (Princeton: Princeton University Press, 1992); K. Rader, Making Mice: Standardizing Animals for American Biomedical Research 1900–1955 (Princeton: Princeton University Press, 2004). 35. R. E. Kohler, Lords of the Fly: Drosophila Genetics and the Experimental Life (Chicago: University of Chicago Press, 1994). 36. Claude Bernard, An Introduction to the Study of Experimental Medicine, trans. Henry Copley Green (New York: Dover, 1957). 37. W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), 104; William Coleman, ‘The Cognitive Basis of the Discipline: Claude Bernard on Physiology’, Isis, 76 (1985), 49–70, at 60. 38. Frederic L. Holmes, Claude Bernard and Animal Chemistry: The Emergence of a Scientist (Cambridge, MA: Harvard University Press, 1974). 39. Georges Canguilhem, Knowledge of Life, trans. Stefanos Geroulanos and Daniela Ginsberg (New York: Fordham University Press, 2008). 40. Christoph Gradmann, Laboratory Disease: Robert Koch’s Medical Bacteriology (Baltimore: Johns Hopkins University Press, 2009). 41. Jonathan Simon and Christoph Gradmann (eds), Evaluating and Standardizing Therapeutic Agents, 1890–1950 (Basingstoke: Palgrave, 2010). 42. Bruno Latour, The Pasteurization of France, (Cambridge, MA: Harvard University Press, 1993). 43. Gerald L. Geison, The Private Science of Louis Pasteur (Princeton: Princeton University Press, 1995), 177–256. 44. Bert Hansen, ‘America’s First Medical Breakthrough: How Popular Excitement about a French Rabies Cure in 1885 Raised New Expectations for Medical Progress’, American Historical Review, 103 (1998), 373–418; Neil Pemberton and Michael Worboys, Mad Dogs and Englishmen: Rabies in Britain, 1830–2000 (Basingstoke: Palgrave, 2007). 45. Christoph Gradmann, ‘Locating Therapeutic Vaccines in Nineteenth-Century History’, Science in Context, 21 (2008), 145–60; Jonathan Simon, ‘Monitoring the Stable at the Pasteur Institute’, Science in Context, 21 (2008), 181–200. 46. P. Chakrabarti, ‘Beasts of Burden: Animals and Laboratory Research in Colonial India’, History of Science, 48 (2010), 125–52.

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47. Daniel Gilfoyle and Karen Brown, Frontiers of Knowledge: Veterinary Science, Environment and the State in South Africa (Saarbrücken: VDM Publishers, 2009). 48. W. F. Bynum, ‘ “C’est un malade”: Animal Models and Concepts of Human Diseases’, Journal of the History of Medicine and Allied Sciences, 45 (1990), 397–413. 49. Ibid. 401–2. 50. Rupke (ed.), Vivisection in Historical Perspective; Robert G. W. Kirk, ‘A Brave New Animal for a Brave New World: The British Laboratory Animals Bureau and the Constitution of International Standards of Laboratory Animal Production and Use, circa 1947–1968’, Isis, 101 (2010), 62–94. 51. Simon and Gradmann (eds), Evaluating and Standardizing Therapeutic Agents. 52. A. F. Bristow, T. Barrowcliffe, and D. R. Bangham, ‘Standardization of Biological Medicines: The First Hundred Years, 1900–2000’, Notes and Records of the Royal Society, 60 (2006), 271–89; P. M. H. Mazumdar, ‘ “In the Silence of the Laboratory”: The League of Nations Standardizes Syphilis Tests’, Social History of Medicine, 16 (2003), 437–59. 53. E. M. Tansey, ‘The Wellcome Physiological Research Laboratories 1894–1904: The Home Office, Pharmaceutical Firms, and Animal Experimentation’, Medical History, 33 (1989), 1–41. 54. Robert G. W. Kirk, ‘ “Wanted—Standard Guinea Pigs”: Standardization and the Experimental Animal Market in Britain c.1919–1947’, Studies in History and Philosophy of Biological and Biomedical Sciences, 39 (2008), 280–91. 55. J. H. Gaddum, ‘John William Trevan, 1887–1956’, Biographical Memoirs of Fellows of the Royal Society, 3 (1957), 282–6. 56. Adele E. Clarke, ‘Research Materials and Reproductive Science in the United States, 1910–1940’, in G. L. Geison (ed.), Physiology in the American Context 1850—1940, (Bethesda, MD: American Physiological Society, 1987), 323–50. 57. Robert G. W. Kirk, ‘Between the Clinic and the Laboratory: Ethology and Pharmacology in the Work of Michael Robin Alexander Chance, c.1946–1964’, Medical History, 53 (2009), 513–36. 58. W. Mills, ‘Valedictory Address to the Graduates in Comparative Medicine and Veterinary Science’, Journal of Comparative Medicine and Veterinary Archives, 17 (1896), 25. 59. P. M. Teigen, ‘William Osler and Comparative Medicine’, Canadian Veterinary Journal, 25 (1984), 400–5. 60. Jean-Paul Gaudillière and Ilana Löwy, ‘Disciplining Cancer: Mice and the Practice of Genetic Purity’, in Jean-Paul Gaudillière and Ilana Löwy (eds), The Invisible Industrialist: Manufacturers and the Production of Scientific Knowledge (London: Macmillan, 1998); Rader, Making Mice. 61. Donna J. Haraway, Modest Witness@Second Millenium: FemaleMan Meets OncoMouse: Feminism and Technoscience (London: Routledge, 1997); Sarah Franklin, Dolly Mixtures: The Remaking of Genealogy (Durham, NC: Duke University Press, 2007). 62. Abigail Woods, A Manufactured Plague: The History of Foot and Mouth Disease in Britain (London: Earthscan, 2004). 63. Robert Bud, Penicillin: Triumph and Tragedy (Oxford: Oxford University Press, 2007). 64. Rhodri Hayward, ‘ “Much Exaggerated”: The End of the History of Medicine’, Journal of Contemporary History, 40 (2005), 167–78. 65. C. Schrabe, ‘Interactions between Human and Animal Medicine: Past, Present, and Future’, in Mitchell (ed.), History of the Healing Professions, 119–33. 66. N. S. R. Maluf, ‘History of Blood Transfusion’, Journal of the History of Medicine and Allied Sciences, 9 (1954), 59–107, at 65.

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67. Susan E. Lederer, ‘Animal Parts/Human Bodies: Organic Transplantation in Early Twentieth-Century America’, in Angela N. H. Creagar and William Chester Jordan (eds), The Animal–Human Boundary (Rochester, NY: University of Rochester Press, 2002), 305–29; Susan E. Lederer, Flesh and Blood: Organ Transplantation and Blood Transfusion in 20th Century America (New York: Oxford University Press, 2008). 68. Akira Mizuta Lippit, Electric Animal Toward a Rhetoric of Wildlife (Minneapolis: University of Minnesota Press, 2000); Nigel Rothfels, Representing Animals (Bloomington/ Indianapolis: Indiana University Press, 2002); Cary Wolfe, Animal Rites: American Culture, the Discourse of Species, and Posthumanist Theory (Chicago: University of Chicago Press, 2003); Cary Wolfe, Zoontologies: The Question of the Animal (Minneapolis: University of Minnesota Press, 2003); Animal Studies Group, Killing Animals (Urbana/ Chicago: University of Illinois Press, 2006); Rebecca Cassidy and Molly Mullin (eds), Where the Wild Things Are Now: Domestication Reconsidered (Oxford: Berg, 2007); Matthew Calarco, Zoographies: The Question of the Animal from Heidegger to Derrida (New York: Columbia University Press, 2008). 69. Donna J. Haraway, When Species Meet (Minneapolis: University of Minnesota Press, 2008), 25; eadem, ‘Situated Knowledges: The Science Question in Feminism and the Privilege of Partial Perspective’, in eadem, Simians, Cyborgs and Women: The Reinvention of Nature (London: Routledge, 1991), 183–201; eadem, The Companion Species Manifesto: Dogs, People, and Significant Otherness (Chicago: Prickly Paradigm Press, 2003).

Select Bibliography Creagar, Angela N. H., and William Chester Jordan (eds), The Animal-Human Boundary (Rochester, NY: University of Rochester Press, 2002). Daston, Lorraine, and Gregg Mittman (eds), Thinking with Animals: New Perspectives on Anthropomorphism (New York: Columbia University Press, 2005). Franklin, Adrian, Animals and Modern Cultures: A Sociology of Human-Animal Relations in Modernity (London: Sage, 1999). Fudge, Erica, Ruth Gilbert, and Susan Wiseman (eds), At the Borders of Being Human Beasts, Bodies and Natural Philosophy in the Early Modern Period (Basingstoke: Palgrave, 2002). Haraway, Donna, When Species Meet (Minneapolis: University of Minnesota Press, 2008). Kalof, Linda (ed.), A Cultural History of Animals, 5 vols (New York: Berg, 2007). Pemberton, Neil, and Michael Worboys, Mad Dogs and Englishmen: Rabies in Britain, 1830–2000 (Basingstoke: Palgrave, 2007). Rader, Karen, Making Mice: Standardizing Animals for American Biomedical Research 1900– 1955 (Princeton: Princeton University Press, 2004). Schrepfer, Susan R., and Philip Scranton (eds), Industrializing Organisms Introducing Evolutionary History (New York: Routledge, 2004).

chapter 32

histor ies of heterodoxy roberta bivins

Since the 1970s, historians, sociologists, anthropologists, medical professionals, media commentators, and consumers have all noted the flourishing of a wild diversity of healing practices that are neither based on nor validated by the biomedical sciences. Since the 1970s too, scholars have struggled to find appropriate language and methodologies with which to define and understand this growth in therapeutic systems and curative options. Initially, responses followed a well-trodden intellectual path: whatever their cultural origins or underlying epistemologies, these systems and their products were defined in relation to what they were not. Thus, many early researchers grouped them under headings like ‘unconventional’ or ‘unorthodox’ medicine, ‘marginal medicine’, ‘fringe medicine’, or—the most enduring (perhaps because the most flexible)—‘alternative medicine’. Some scholars, many commentators, and most medical professionals dismissed them simply as ‘quackery’. Consumers, meanwhile, opened their wallets and purchased these commodities and forms of expertise under every label applied to them. Initially regarded as a transient flowering of counterculture or a medical fad, this phenomenon endured. Its persistence in the face of outspoken professional disapproval, high levels of patient demand, and the economic imperatives of biomedically driven health care systems has forced professional reconsideration of some purportedly ‘marginal’ challengers to biomedical monopoly. Since the 1990s, certain systems have been reconceptualized as ‘complementary medicine’, as practices that might be incorporated in various ways into the therapeutic mainstream. Contenders for such mainstream status include acupuncture, chiropractic, homoeopathy, osteopathy, and, sometimes, naturopathy and therapeutic touch. Not all practitioners or consumers wished, however, to cede the alterity of their chosen therapeutic modalities; nor were all systems considered for such inclusion by biomedical organizations or professionals. Thus, many healers and health-seekers continued to insist that their chosen systems were ‘alternative medicine’. Moreover, one highly visible aspect of this conspicuous medical pluralism has been the popularity of

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medical practices and systems from around the world. Clearly, defining medical systems originally rooted in, and entirely ‘orthodox’ to, other cultures as either ‘alternative’ or ‘complementary’ is suspiciously akin to the tradition of scholarship that prompted Edward Said’s original critique of ‘orientalism’.1 Grouping them under the label of ‘ethnomedicine’, meanwhile, unthinkingly reifies biomedicine’s claim to universality. So what is the interested scholar to do? Under what name can we study and discuss this rapidly expanding collection of health-seeking and therapeutic phenomena? Here, I have chosen ‘heterodox’, which captures the oppositional qualities of ‘alternative’ without insisting on them and thereby ruling out complementarity. ‘Heterodox’ does not completely avoid the dangers of dichotomy; it still implies that biomedicine is universally ‘orthodox’. Considered globally, biomedicine is, at best, only one orthodoxy among several. However, in the sense of referring to different beliefs, ‘heterodoxy’ at least does not assume either a ranking or a specific geography, and can therefore include medical systems from any culture. Nor has it been easy for researchers to find appropriate descriptive language for what I have been calling ‘biomedicine’. Initially, this system operated under the rubric ‘Western’ or ‘scientific’ medicine. These terms, however, are obviously problematic. ‘Conventional’, ‘orthodox’, and ‘regular’ designations have all been used, but fail to capture the complexities of biomedical practice outside the region of its origin. Some scholars have attempted to avoid this debate by instead referring to biomedicine as ‘cosmopolitan’; this appealing expression unfortunately ignores the fact that many, if not all, of the medical systems now under discussion are also ‘cosmopolitan’. Like ‘heterodox’, ‘biomedicine’ is at best an imperfect appellation: it erases enormous heterogeneity and historical pragmatism. However, it does suitably capture the epistemological importance of materialism and the allied sciences to the system. This episteme is, in turn, at the heart of the historical controversies (and controversial histories) with which this chapter is concerned. As with all areas of the history of medicine—but perhaps to an even greater degree— the history of heterodox medicine has been marked by contention between those who have written it from a medical perspective and those who have examined it as a social phenomenon. In part, this has been due to the very different agendas with which these two groups of scholars have approached the topic. Medics (and until recently many historians of the medical mainstream) have, by and large, aimed to ‘debunk’ heterodox practices and claims and to portray their practitioners as quacks, fraudsters, or fools. Consciously and deliberately, such authors have been addressing the present-day ‘problem’ of medical pluralism, as much as interpreting its past. Consequently, these accounts have often ignored the social, political, and indeed the medical contexts in which such practices have thrived, as well as any benefits heterodoxy has had either for patients or for medicine as a whole.2 Social and cultural historians, on the other hand, have examined medical heterodoxy principally for the valuable perspective such studies offer either on the emergence of medical orthodoxy or on popular perceptions of health, medicine, and the body.3 Neither side is ever completely satisfied with the work of the other; indeed the groups generally concur only in their disdain for practitioner- and patient-historians who uncritically adulate their heterodoxy of choice.4

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At least until the advent of social history, histories of alternative medicines also struggled to overcome the frequent conflation of these practices with ‘quackery’—a conflation profoundly influenced by the dismissive hostility of established medicine to systems that were simultaneously cosmologically heretical and economically competitive. Somewhat ironically, quackery as a subject has been better integrated into the historiographies of medicine and societies than has analogous work on cross-cultural or alternative medicine. This is largely because quackery is fundamentally a part—albeit a discredited, disdained, sometimes dangerous, or even illegal part—of any medical orthodoxy: it is precisely from the relatively uncontested popular acceptance of that orthodox system that quackery draws its own authority. Although their research may have been prompted and informed by the current popularity of heterodox medicine, contemporary social historians do not treat ‘alternative’ and ‘complementary’ practices as inherently problematic or fraudulent and do not assess them principally in terms of their biomedical efficacy. To further muddy the historiographical waters, two other genres of self-care have also—though only by some historians and in some contexts—been categorized as ‘alternative’, ‘complementary’, or otherwise heterodox. Herbal remedies have an ambiguous place in medical historiography. They were, of course, a mainstay of the Western pharmacopoeia and mainstream therapeutics well into the nineteenth century, and remain a crucial part of non-biomedical therapeutics globally. However, herbalism has also been conventionally regarded as the acme of European and American folk or traditional medicine, and certainly in the nineteenth and twentieth centuries modified and systematized forms of herbalism have been at the core of explicitly alternative medical systems including Thomsonianism, Eclecticism, and the extremely popular and highly commercialized Bach Flower remedies. Likewise, no consensus has yet emerged about how to categorize the diversity of medicinal ‘self-help’/self-caring behaviours, whether manifested through patent medicine (now ‘over-the-counter remedies’), therapeutic appliances, special diets, dietary supplements, or health-related practices of physical culture. While often rooted in the medical orthodoxy of the day, these items can change their cultural valence once they are firmly in the hands of patient-consumers and commercial suppliers. In summarizing the history of heterodox medicine, this chapter will not address in detail the myriad forms of quackery that have often dominated (particularly medical) accounts of the history of alternative medicine. Nor, beyond suggesting that they will constitute vital connections to be explored by future scholars in this sub-field, will it address self-prescribing, patent, and over-the-counter medicines, or self-help and selfhealing practices. It will focus on heterodox medicine in Europe, the post-Columbian Americas, and the post-colonization Antipodes, not least because it is in these cultures that a self-identified and deliberately (if wishfully) exclusive orthodoxy has been at the heart of medical ideology and professional development and fundamental to medical consumerism. And this brings me to the last medical genre under consideration here: crosscultural medicine, a term which—like ‘heterodox’ and ‘biomedicine’—demands some

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interpretation. For clinicians, medical researchers, and scholars studying exclusively or predominantly biomedicine from the perspectives of sociology and anthropology, ‘cross-cultural medicine’ refers to the tools and practices developed to help biomedical practitioners better serve or understand patients whose own therapeutic expectations and experiences are inflected or shaped entirely by non-biomedical healing practices. For historians, by contrast, ‘cross-cultural medicine’ refers to medical knowledge, and especially to medical techniques, technologies, and practices, that have crossed cultural boundaries. In general, the boundaries medically transgressed (and historically assessed) have been geographically as well as culturally defined— exchanges between the scholarly medical systems have received the most scholarly attention.5 However, there is no inherent reason why scholars of ‘cross-cultural medicine’ could not study, for example, the ways in which medical knowledge crosses the often more closely guarded border between popular and professional/biomedical knowledge. Moreover, historians are also now examining both types of liminality not only in the developed, but also in the developing, world, presenting intriguing perspectives on biomedicine both as an ‘alternative’ system and as a competing ‘orthodoxy’ in cultures that have well-established medical systems of their own.6 The extensive literature examining the global spread of biomedicine certainly falls under this big tent—though more commonly, and very tellingly, such studies are grouped instead under the rubric of ‘colonial science/medicine’—not least because researchers have been both more interested and better enabled to study the political and social motivations and ramifications of such exchanges for empire. Twentieth-century studies meanwhile have, with a few honourable exceptions, naturalized this current of exchange almost completely.7 Whichever the border, anthropologists and folklorists were the pioneers of this expansive cultural territory, and their work continues to dominate understandings of CAM (a commonly used abbreviation for the amorphous but convenient ‘complementary and alternative medicine’, generally considered to include the more popular heterodox medical systems, including acupuncture, homoeopathy, naturopathy, and chiropractic) in contemporary European and American contexts, as well as ‘ethnomedicines’ within their cultures of origin. Their work remains a valuable and underexploited resource for historians particularly of cross-cultural but also of alternative and complementary medicine, both for the historical data collected and for the theoretical insights offered. The remainder of this chapter will sketch out the history of medical heterodoxy as it has been (re)written over the past two decades. This survey will use brief case studies to examine the emergence of a global medical marketplace of materia medica and ideas from the Age of Exploration to the end of the Enlightenment. It will then turn to the rise of explicitly ‘alternative’ systems like mesmerism and homoeopathy in the late eighteenth and nineteenth centuries and the (partial) incorporation of some of those systems into biomedicine in the twentieth century, under the rubric of ‘complementary medicine’. Finally, it will look at the recent historiography of heterodox medicine, and lay out potential directions for future scholarship.

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roberta bivins

The emergence of heterodoxy: mediators, marketplaces, and exchanges Currently, it is only possible to construct a history of ‘medical heterodoxy’ for the ‘Western’ world. Only for Europe and North America is there sufficient depth of scholarly research into both mainstream and marginal practices to allow such an overview. Moreover, for the rest of the world, it is not yet clear that the concepts of medical orthodoxy and medical heterodoxy are even appropriate. In East and South Asia, and among Latin American and African populations, alongside ample evidence of determined practitioner and patient pluralism, there is little trace of biomedicine’s drive for professional exclusivity and cosmological homogeneity.8 Of the three categories of medical heterodoxy of which this chapter speaks, then, only one can be discussed as existing more or less globally: cross-cultural medicine. Archaeological evidence of the transfer of medical commodities—and thus medical knowledge at its most basic—pre-dates the scholarly medical traditions. The emergence of those traditions in China, the Indian subcontinent, and the Mediterranean world brings with it evidence of the exchange of medical ideas and concepts as well. The transfer of ideas between the cultures of the Mediterranean—Egyptian, Greek, Roman—is also well known. Through cultural crossroads like Baghdad, similar transfers took place between India and the Islamic world. The complex and interwoven trading networks of the Indian Ocean facilitated exchanges of medical goods and medical knowledge between its cultures long before Europeans joined the trade.9 Commodities and ideas also flowed between China and Japan, and between India and China, via Tibet and Ceylon. These, too, have received some scholarly attention.10 Equally crucial are the exchanges that took place between the Islamic and Christian worlds during the Crusades, and alongside the great waves of translation and transmission that shaped the European Renaissance.11 It is notable that these exchanges also prompted early signs of Western intellectual hostility to non-Western medical and scientific expertise. The basis of these complaints—an assumption of cultural superiority—may seem familiar, but that confidence was rooted in religion: Christianity was the sole source of true knowledge, in matters mundane as well as divine.12 Europe’s taste for monism, at least, survived the epistemological shift from faith to science. With the vast expansion of intercultural contact in the early modern period, opportunities for medical exchange across cultural boundaries likewise expanded, for Europe most of all. The scholarly systems of medicine (and unsystematized secular medical practices) shared significant features at the beginning of this period.13 Classical Western (including Islamic), Ayurvedic, and Chinese medicine all had access to the body’s physical and social context, its surface and visible membranes, its appetites, ingesta, and excreta, and its temperature and pulses. The body’s interior was, at least in life, equally mysterious to all. Across secular medicine, these data were interpreted in relation to models of bodily constituents conceptualized as physical and/or ethereal fluids—for

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instance, humours, dosas, or qi—operating in dynamic relationship with the body’s environment. A final shared component of medical thinking was the idea that the body was a microcosm of the universe: what was true in the greater world would be reflected in the smaller. Thus, barriers of language and incomplete transmission aside, practitioners from any one of these cultures could potentially find common ground with their counterparts from another. From the sixteenth through the eighteenth centuries, such common ground was sometimes sought, not least as a vehicle for securing European health in novel environments. The Spanish, French, and English sifted their New World Empires for medicinal plants and compounds.14 In Goa, the Portuguese established hospitals, to the admiration of the indigenous population—but simultaneously learned to admire the skills of the local healers in managing tropical diseases.15 In India, the French and English battled for control—but both nations studied the scholarly traditions and local knowledge of the subcontinent with enthusiasm and (sometimes grudging) respect. And at Batavia and in their Japanese outpost at Deshima, the Dutch carefully observed and reported on the medicine of their trading partners, subjects, slaves, and hosts—and were carefully observed in their turn by what would become known as the Rangaku School. Jesuits from the Catholic nations of Europe, reporting back on the fruits of their missionary endeavours, too, opened channels by which medical and other knowledge could be exchanged, particularly in relation to China and East Asia. The degree to which these exchanges were valued by each side, the extent to which they constituted two-way traffic, and the levels of practical and intellectual accommodation offered by the exchanging cultures varied dramatically over both time and space. For the most part, the perspectives of the non-European partners in these encounters remain to be explored.16 European perceptions of this exotic knowledge are better known, as the examples of acupuncture, moxibustion, and Chinese medical knowledge demonstrate.17 A closer look at these cases will shed some light on the processes of cross-cultural medical exchange, from observation, examination, and transmission through to reception, evaluation, and adaptation. Acupuncture is the use of therapeutic needle puncturing, to different depths beneath the skin, at specific known locations on the body’s surface to affect sometimes remote symptoms or conditions of imbalance. The practice is based on the Chinese body atlas of interconnecting vessels and channels and on Chinese perceptions of the body as a dynamic system of circulating physical and ethereal fluids. Moxibustion is based on the same system and principles, but involves burning small cones of vegetable fibre on the same mapped surface points. Both techniques came to wider European attention in the late seventeenth century, through the published and personal reports of European observers in China, Japan, and the Indonesian archipelago. Yet the two techniques met with quite different initial responses. Transmitted simultaneously along both personal and professional networks, and through published medical observations, travellers’ tales, and user accounts originating with experimentally minded Europeans at home and abroad, information about moxibustion reached lay and medical audiences alike. Initial reports emphasized its value in a condition—gout—which commonly afflicted an influential and well-connected

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demographic: affluent middle-aged men. Moreover, European medicine had no satisfactory or effective treatment for gout, only painful and risky half-measures, or admonitions to endure its rigours with patience. Finally, moxibustion was easily analogized to the classical technique of actual cautery. Thus, it appealingly combined the familiar with the exotic. Information about acupuncture, by contrast, was principally transmitted through medical channels, via the Latin treatises of Wilhelm Ten Rhijne (1683) and Engelbert Kaempfer (1712), both doctors to the Dutch mission in Japan. Only fleeting—and not particularly enticing—mentions of the technique appeared in the lay press until Kaempfer’s account was translated into English as an appendix to his The History of Japan. These professional communications were not accompanied by user reports, though both doctors described their own first-hand observations of the technique’s efficacy and its relative gentleness and ease of application.18 Only in the early nineteenth century would the conditions that fostered moxibustion’s adoption by European medicine—multilayered transmission, the intersection of personal and professional networks, patient dissatisfaction, and increased (if often confused) familiarity—come together to spark a more thorough investigation of acupuncture by both patients and practitioners. Moxa and acupuncture, which in their original context represented a nexus of medical knowledge, medical practices, and a specific material culture, became in the West simple techniques. The knowledge and cosmology that underpinned each practice was rapidly stripped away. So what happens to medical knowledge itself in the process of crossing cultural boundaries? Here again, it is worth looking at an example parallel to the two already described. Descriptions, more or less detailed, of Chinese anatomical theory and pulse diagnosis featured in many early accounts of China and Japan.19 Travellers seeking to describe this complex system faced a number of hurdles, particularly in terms of acquiring, and of course translating, appropriate texts.20 However, a still greater hurdle awaited these accounts on their arrival in Europe: Chinese medical ideas and knowledge were presented to a medical audience increasingly wedded to anatomical understandings of the body and its circulatory system borne of dissection. While systemic, humoral models of health and illness would persist until well into the nineteenth century, the highly material, anatomized body was becoming the only acceptable basis for claims about physical function and structure by the early eighteenth century. Not only were the Chinese known not to dissect, but the body map upon which both acupuncture and moxa were based seemed to European eyes almost deliberately contrary to anatomical (if not experiential) fact. So, to all intents and purposes, it was discarded. Even highly favourable accounts of Chinese pulse diagnosis, which stirred considerable interest, foundered on the rock of anatomy, despite the best efforts of medical enthusiasts like the English physician, Sir John Floyer (1649–1734). Expert knowledge proved far less portable than practical expertise, at least until the twentieth century. Perhaps it remains so: while many consumers find Chinese medical theories fascinating and indeed satisfying, these theoretical understandings—and their practical ramifications—resist assessment by randomized controlled trials (RCTs) and have not been included as a part of ‘complementary’

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acupuncture. Of course, there are far more straightforward examples of ‘travelling medicine’ than acupuncture and moxibustion, complex systems of knowledge, practice, and material culture. Colonial bio-prospecting, as Londa Schiebinger and others have demonstrated, was commonplace. However, even when such local knowledge was actively sought, it was rarely considered uniquely authoritative.21

Policing the boundaries of medical practice Around the pre-modern world, there were many therapeutic options available to the suffering and the healthy alike: the sick could seek cures from trained healers, from priests or shamans, or use lay knowledge and traditions, or prayers and magical interventions, to treat themselves. Their chosen cures might be local or far-flung. Those fortunate enough to be hale could take advice on maintaining that state from a similar range and diversity of sources. However, describing any one of these approaches to the body as ‘alternative’ ignores their essentially equal standing and social authority, and grants an ahistorical privilege to a certain kind of healing—generally, those practices that share epistemological roots with contemporary biomedicine. ‘Alternative medicine’ as we understand it today could only emerge in relation to an established medical orthodoxy. In other words, the systems that have shaped our contemporary understanding of ‘alternative medicine’ were themselves shaped by the fact that they emerged in opposition to a medical establishment that was—already in the late eighteenth and early nineteenth century—making claims to unique, exclusive, and superior knowledge about the body and disease and, consequently, to a rightful monopoly over the art, science, and business of healing. The reactions of the founders of three early alternative systems of medicine, Samuel Thomson (1769–1843), Franz Anton Mesmer (1734–1815), and Samuel Hahnemann (1755–1843), to such assertions of exclusivity are revealing. Samuel Thomson, uneducated and of pioneer stock, developed and advanced his own school of botanical medicine in deliberate opposition to the medical orthodoxy that had failed him and his family in rural New Hampshire and the elitist exclusivity that, to him, it represented. Mesmer and Hahnemann, however, were both trained physicians (and European urbanites); unlike Thomson, they initially saw themselves as adding to, or reforming, established medicine, rather than as its adversaries. However, their ‘discoveries’ of, respectively, a new physical fluid (animal magnetism, believed by Mesmer himself to be an ethereal substance of the same order as electricity, magnetism, and even gravity) and a novel therapeutic paradigm (‘similia similibus curentur’, or ‘like cures like’, in minuscule amounts) were rejected by the medical establishment. Only then did these men and their disciples come to see themselves as Thomson had seen himself from the beginning: as opponents of an arrogant and monolithic medical orthodoxy. In similar ways, and over the course of a century’s bitter

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rivalry, this most heated debate in medicine—between ‘regulars’ and ‘irregulars’, or as the mainstream profession would come to argue, ‘scientists’ and ‘sectarians’—forged alliances and unifying identities for practitioners on both sides.22 Cross-cultural medical techniques and systems, interestingly, were rarely drawn into these battles in the nineteenth century, at least in Europe or North America. This may be because cross-cultural practices were still simply too inconspicuous to be either threats or allies. Research on acupuncture, for instance, has shown that while its use was geographically widespread in Britain, its practitioners were never numerous. Moreover, these ‘acupuncturists’ were drawn principally from the ranks of the regulars, not the sectarians. Only in relation to Chinese herbal medicine does a different picture emerge, and then only in Australia and North America, with their large ethnically Chinese populations. By the end of the nineteenth century, major cities in both Australia and North America boasted notable Chinese practitioners with growing practices outside the Chinese community. Preliminary research indicates that considerable hostility did emerge in these locations and that the orthodox profession sought to classify these healers as quacks, frauds, and threats to public health—exactly as they had fought to do with the medical sects.23 In Australia, these attempts met with some success, but in North America, the orthodox profession faced stiff legal resistance from the ethnic Chinese community, Chinese practitioners, and their growing non-ethnic clientele. Only a postSecond World War ban on imports from the People’s Republic of China finally closed practice doors.24 By the time America’s Chinese pharmacies were frozen out by Cold War politics, the nineteenth century’s flourishing alternative medical systems had already long been in decline. Many historians have compellingly argued that the decline of ‘alternative medicine’ from its nineteenth-century heights of popularity and influence was due to the emergence of a radically different source of medical authority and epistemology: the ‘rise of science’. Certainly, its promoters recognized themselves as representatives of a new system, one self-consciously above the testy disputes of the past. ‘Scientific medicine’ was to be beyond sectarianism and capable of absorbing ‘good’ medicine from any system. As Abraham Flexner put it: Prior to the placing of medicine on a scientific basis, sectarianism was, of course, inevitable. Every one started with some sort of preconceived notion; and from a logical point of view, one preconception is as good as another. Allopathy was just as sectarian as homeopathy . . . But now that allopathy has surrendered to modern medicine, is not homeopathy borne on the same current into the same harbor? . . . Scientific medicine therefore brushes aside all historic dogma. It gets down to details immediately. No man is asked in whose name he comes—whether that of Hahnemann, Rush, or of some more recent prophet. But all are required to undergo rigorous cross-examination. Whatsoever makes good is accepted, becomes insofar part, and organic part, of the permanent structure.25

In many ways, early-twenty-first-century ‘complementary medicine’ can be directly linked to this initial idealistic conception of ‘scientific medicine’ as the natural harbour of all genuinely curative knowledge and practices, whatever their origins. It is worth

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thinking about the characteristics shared by all of the practices and systems now commonly described as ‘complementary’. All are secular in orientation, rather than faithbased. All have been professionalized along the same lines as biomedicine: that is, they have developed professional associations, brought in self-regulation and sought out formal regulation, established specific training standards or educational institutions, and communicate via a wide range of professional journals. Aspects of each are relatively accessible to bioscientific scrutiny via the RCT. All are widespread, popular, and empirically successful, particularly for treating the chronic conditions that have proved to be most intransigent to biomedical interventions. And crucially, all ‘complementary’ therapies and therapists have been willing to accept the primacy of the biomedical approach—they offer services and approaches that ‘complement’ biomedicine, rather than replacing it.

Tracing transgressive medicine: the historiography of alternative, complementary, and cross-cultural medicine Historiographically, studies of ‘cross-cultural’ and ‘complementary’ medicine represent the intersection of new scholarly concerns in the wider discipline of history with new, or newly visible, trends in medical practice and medical consumption. In the past decade, these and other new historical concerns have also begun to reshape studies of straightforwardly ‘alternative’ medicine. However, most treatments of the subject can still be grouped into five broad categories. Perhaps the oldest approach to the history of alternative medicine has taken the form of biography (or, all too often, hagiography) of specific ‘leading lights’. The lives of Hahnemann, Mesmer, Thomson, Mary Baker Eddy (1821–1910), the founder of Christian Science, and others have been recounted by their followers and critics alike as evidence for and against their respective systems since the nineteenth century. More recently, historians have entered the fray, for example with Ronald Number’s study of Ellen G. White (1827–1915), healer and founding member of the Seventh Day Adventist Church, Norman Gevitz’s account of Andrew Taylor Still (1828–1917), founder of osteopathy, and John Haller’s treatment of Samuel Thomson. Extending the framework of conventional biography, these volumes offer social histories of the systems for which each of their subjects became known.26 Founder biography and prosopography are also conventionally included in social histories of specific heterodox systems. Such detailed studies of single, well-defined ‘alternative’ systems have become an established part of the literature. Often, they have been shaped around the debates between orthodoxy and heterodoxy, as with Phillip Nicholls’s pioneering British-focused

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Homeopathy and the Medical Profession, and two roughly parallel studies of the US case.27 Until relatively recently, many were written either by proponents or opponents of the system in question. Since the advent of social history, many of the major alternative systems—for instance, homoeopathy, mesmerism, chiropractic, osteopathy, naturopathy, hydropathy, Christian Science, electrotherapeutics, and quasi-medical phenomena like phrenology—have received renewed historical attention. Such studies have drawn on a far wider range of source materials than their predecessors, which relied predominantly on foundation texts, medical commentaries, and only occasionally other textual sources. Popular accounts, newspaper and magazine articles, advertising, material culture, contemporary fictional and literary representations, patient and practitioner diaries and letters, court records and legal documents, and of course the professional literatures have all been pressed into service. In the process, authors like Alison Winter and Rennie Schoepflin have demonstrated connections between these systems and science, popular—and elite—cosmology, and the wider political system.28 In these studies, it becomes clear that alternative systems of medical practice, and the alternative visions of embodiment that they represent, open a window on crucial phenomena like the (partial) erasure of the patient and the experiential from the authoritative discourse of biomedicine—all essential to the shaping of modern highly materialistic biomedicine. Similarly, they reveal the persistence of models of the unseen, the mystical, and the vitalist in cultural understandings of embodiment; and equally the enduring power of religious and moral elements in lay (though often denied) models of health and disease.29 One aspect that remains as yet underexplored by historians is the patient’s perspective on each of these systems. Two recent volumes have appeared, exploring homoeopathy ‘from the bottom up’, but this area of the field remains very much a frontier for future scholars.30 Another productive historical approach to understanding the emergence and experience of alternative medical systems has been comparative, through monographs and, more commonly, edited volumes looking at multiple systems. Three key examples of the latter, all published in the late 1980s, and edited by Roy Porter and William Bynum, Roger Cooter, and Norman Gevitz, are frequently credited with opening the field of the history of alternative medicine for exploration as social history.31 While these collections focused on the eighteenth and nineteenth centuries, and on the United States and Britain, historians have since expanded the geography of alternative medicine and stretched its chronological frame both back into the sixteenth century and forward into the twentieth.32 Marijke Gijswijt-Hofstra, Hilary Marland, and Hans de Waardt, in their edited volume Illness and Healing Alternatives in Western Europe, also give considerably greater attention than usual to the roles of magic, religion, and folk belief as alternative medicine and explore the degree to which approaches to sickness and healing have been disenchanted or not. It is interesting to compare these works, written as the new surge of interest in alternative medicine became conspicuous, with texts written about alternative medical systems just before this new wave crested. For example, the classic collection Marginal Medicine, published in 1976, offered a sociological perspective on medical heterodoxy which noted that in the 1970s, health-seeking behaviours that took patients

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away from orthodox medicine were generally studied ‘within the framework of deviant behaviour’.33 A key but rarely discussed feature of the emergence of alternative medicine has been the diffusion of medical orthodoxy—medical beliefs, theories, facts, and practices—from medical circles to the general public. While Roy Porter and others have examined the latter as an important phenomenon in its own right, few have tackled it in terms of its role in the delineation of heterodox knowledge, approaches, therapeutics, and spaces.34 More recently, volumes tackling alternative and complementary medicine from sociological, anthropological, and medical perspectives have appeared, generally with one or two essays addressing the longer history of contemporary enthusiasm for the medically heterodox.35 Among the monographs, those of James Whorton and Hans Baer—both exploring the North American terrain—exemplify perhaps the most synthetic analyses; they also represent very different approaches to writing the history of alternative medicine.36 Both offer an overall hypothesis for the flourishing of alternative medicines in the nineteenth century and their apparent decline and rise in the twentieth century. However, Whorton comes to his subject from the perspective of a historian, while Baer is by training a sociologist. Such comparative studies, monographic and collected alike, offer their readers wider perspectives on the overall causes and contexts of health-seeking beyond the boundaries of orthodoxy. They look at consumers and practitioners in an array of different times, places, and institutional spaces, and through the lenses of professionalization, social construction, and cultural and social history. Economic history, sadly, is understudied, particularly in relation to the larger systems, and would certainly reward further investigation. Few studies are integrated, looking at heterodox and orthodox practice together (though many authors note that this is how heterodoxy is generally consumed by patients), or focus not on their battles but on their similarities. Future scholarship on medical pluralism in the biomedicalized West will doubtless explore these perspectives. Institutional histories, though comparatively rare, have also proven revealing. Historiographically, these parallel the institutional history of orthodox medicine, with a similar division between institutional hagiographies and highly sophisticated social histories. Naomi Rogers’s An Alternative Path, an account of the last surviving homoeopathic medical school in the United States, falls into the latter category and shows the remarkable analytic power to be gained from intimate knowledge of a specific institutional context.37 John Haller has done similar work for the Eclectic Medical College of Cincinnati.38 In a second volume, Kindly Medicine, he has taken a slightly different approach. Instead of focusing on one medical school, he looks closely at a number of them in order to explore the trajectory of physio-medicalism (an offshoot of Thomsonian botanical medicine) through its internal politics, its relations with other sectarian systems, and its education traditions.39 As yet, only a few alternative systems and their institutions have figured in this genre (certainly at book length). Our understanding of other heterodox approaches would certainly be improved by similarly detailed understandings of their institutions: where and why did such institutions flourish or decline and what kinds of institutions were they? Did particular heterodoxies build hospitals, or

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dispensaries, medical schools or laboratories, professional associations or pharmaceutical firms? Whom did they serve and who served in them? The journals—historical, but also anthropological and sociological—are rich in studies of particular episodes and debates in the emergence of medical heterodoxy and local studies of different systems, practices, or marketplaces. Sometimes these are integrated into larger studies of an area, institution, or orthodoxy. Other studies have examined medical heterodoxy in relation to such key analytical categories as gender and class; thus we have studies of the distinctive appeal of both hydropathy and homoeopathy to women, whether as consumers or practitioners, and the role played by tensions between homoeopathy and orthodoxy in debates over the admission of women to the medical profession.40 Race remains underexplored in this context. As we have seen, only with the emergence of the social history of medicine did histories of alternative medicines emerge from the shadow of ‘quackery’. Debates initiated within professional medicine about the relative efficacy of such treatments coloured traditional historical analysis and obscured the fundamental epistemological differences between quackery and medical heterodoxy. By contrast, social historians’ interests in consumers and marketplaces were amplified by the heightened visibility of medical responses to patient dissatisfaction and the economics of chronic morbidity. This renewed scholarly interest in medical phenomena that had been relegated to the historiographical as well as the therapeutic fringes. Likewise, with the emergence first of ‘world’ and then of ‘global history’, historians of medicine too have increasingly turned their attention to phenomena that transcend the boundaries of the nation-state. This is not an entirely novel approach in the history of medicine or the closely associated histories of science and technology. The enduring, if highly contested, claims to universalism made by practitioners of the knowledge produced in each of these fields long encouraged a certain degree of what might be fairly called internationalism (but certainly not ‘globalism’) in the traditional historiography of science, technology, and medicine. Indeed, William McNeill’s foundational text in world history was rooted in the study of phenomena central to the history of medicine: Plagues and Peoples.41 Studies in the relationship between medicine and empire— whether as a ‘tool of empire’, empire’s moral justification, or a lens through which to examine colonized cultures and peoples—broke ground for more nuanced studies of cross-cultural medicine. This shift in historiographical focus from bounded practices to unbounded processes can be exemplified by changes in the (Western) historiography of our earlier case study, acupuncture, and indeed Chinese medicine in general. From the initial appearances of acupuncture on the European stage in the seventeenth-century writings of the Deshima medics and Jesuit missionaries in China, acupuncture’s history, as well as its methodology and embedded body model, attracted attention from Western practitioners and consumers alike. By the early nineteenth century, that history had been conventionalized. Depictions generally included one of a set of exotic martial origin myths, citing either tattooing to identify combatants in primitive battles or painless encounters with fortuitously placed missiles. References to a semi-sacred history in China, and an arcane and metaphysical body map and

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descriptions of elaborate training methods (and particularly the famous mercury-filled statues for demonstrating knowledge of acupoints) appeared frequently. Most narratives referred to examples of hidebound empirical practice in the exotic East and the ‘discovery’ and transmission of the technique by Europeans in East Asia to their medical or religious brethren at home. The present and future of ‘acupuncture’ in these accounts was to depend on independent European verification of the technique’s efficacy and modus operandi, and the history of acupuncture served only as a colourful gloss on the necessity of such efforts. While speculative references to arrows and tattoos have now been replaced by archaeological findings, much of the rest of this ‘history’ remained canonical at least until the fall of the Bamboo Curtain added a final chapter—the emergence of ‘acupuncture anaesthesia’, as demonstrated on an American journalist covering Nixon’s 1972 visit to China. The implicit assumption that Chinese medicine in China remained static both before and after its discovery by scientific European eyes persisted. Moreover, so did the assumption that the universal truths of science were an appropriate metric by which to measure any medical practice. When Lu Gwei-djen and Joseph Needham wrote their magisterial study of acupuncture, Celestial Lancets, in 1980, they assessed its contributions to ‘medical science’ (by which they meant biomedicine) and evaluated its therapeutic efficacy entirely through the lens of contemporary biomedical research.42 Lu and Needham’s study of acupuncture remains invaluable for its thoroughness and insight, not least in its documentation of the technique’s initial receptions outside of China—that is, of acupuncture and moxibustion as cross-cultural medicine. However, historians of cross-cultural medicine now use different tools of assessment to answer different questions. The phenomenon of interest is generally not the technique, drug, or preparation, or aspect of medical knowledge itself—though this may yet prove a significant flaw—but rather the networks of people, practices, and agents (animate or inanimate) that coalesce around ‘travelling medicine’. These in turn shed light on a whole range of complex cultural processes and moments central to global and transnational history.

Conclusion Fundamental myths have plagued the writing of the history of heterodox medicine: as well as the ‘quackery’ conflation, the history of ‘alternative medicine’ has battled with visions of efficacious alternatives ruthlessly suppressed by an orthodox conspiracy and notions of rigid dichotomy between medical heterodoxy and orthodoxy. The twentiethcentury history of ‘complementary medicine’ will certainly begin to blur that overdetermined boundary. However, studies of the history of ‘alternative medicine’ and indeed of biomedicine have already begun to challenge the dichotomy. Recent work has increasingly stressed the continuities, rather than the discontinuities, between the nineteenth century’s medical orthodoxy, ‘heroic medicine’, and its heterodoxies, from

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homoeopathy to chiropractic and Christian Science. As Don Bates asked in 2002: ‘Why not call modern medicine “alternative”?’43 Studies of cross-cultural medicine too have their myths, whether of intellectual stasis, or of empirical purity persistent for millennia. Such myths crop up, with particular frequency in studies of Chinese medicine and Ayurveda. As the historiography of these medical systems in their cultures of origin has become more sophisticated, these myths have been shattered. No medical system is static, and few if any are truly isolated. Yet patients and practitioners of these systems outside their cultures of origin still cling to ideas of ‘4,000-year old traditions’ untouched by change. What is the appeal of such ideas and are transplanted medical systems more or less subject to change than parallel systems of the host or origin cultures? Many other directions too will prove revealing and fruitful: there are few comparative studies either between therapies or with cultures of orthodox medicine and self-healing. Even the major alternative and cross-cultural systems have rarely been studied transnationally. Moreover, it will be of considerable interest to discover whether we can discuss ‘alternative’ or ‘heterodox medicine’ as globally relevant categories of analysis—or whether we must instead divide medicine into other categories. Perhaps ‘established medicine’ and ‘quackery’ will serve us best in medical systems where pluralism is not merely a phenomenon of the medical marketplace, but is its institutionalized and regulated structure, as is the case in parts of South and East Asia. As I have already suggested, we need far more studies of heterodox medicine from the patient’s perspective and through the lens of practice. Preliminary work has suggested that heterodox medicine can be read as exemplifying continuity, rather than discontinuity, in medical beliefs and systems—not within the profession, to be sure, but amongst medical consumers and in the wider medical culture. It represents the persistence of the experiential, the systemic (these days, all too often obscured under the unduly fey heading of ‘holistic’), the empirical, and most of all the inclusive in medicine. This is not by any means necessarily the wish of heterodox medical practitioners, many of whom seek exactly the same kinds of exclusivity and authority over the body that have become so characteristic of biomedical orthodoxy. Nor is it an inevitable part of all heterodox medical systems: Chinese medical practitioners, for example, won the envious admiration of their European brethren in the seventeenth and eighteenth centuries precisely for the unquestioned and unquestioning authority they apparently wielded over their patients’ bodies. Similarly, heterodox medical systems could offer scholars an avenue along which to explore the meanings of ‘holism’ and styles of ‘holistic’ practice. When and why did the orthodox profession give up on holism, or what Hau calls the ‘synthetic gaze’? Whether studying alternative, complementary, or cross-cultural medicine—or for that matter, the medical or biomedical mainstream—historians need a more critical approach to the borders created and policed by practitioners of both orthodox and heterodox medicine and to include fuller consideration of religion, self-help, and the whole range of healthseeking behaviours. For users and consumers, these approaches to well-being seem to function far more like a continuous spectrum than distinct modalities. This is surely a perspective historians must respect and explore.

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Notes 1. Edward Said, Orientalism (New York: Pantheon, 1978). 2. For a flavour of this literature, see ‘The Harveian Oration: Lord Moran On Quackery’, British Medical Journal, 2 (4790) (25 October 1952), 936–7; ‘The Flight from Science’, British Medical Journal, 280 (6206) (5 January 1980), 1–2; James Harvey Young, The Toadstool Millionaires: A Social History of Patent Medicines in America before Federal Regulation (Princeton: Princeton University Press, 1961); idem, The Medical Messiahs: A Social History of Health Quackery in Twentieth Century America (Princeton: Princeton University Press, 1967). 3. Classic and still valuable collections and monographs in these veins include W. F. Bynum and Roy Porter (eds), Medical Fringe and Medical Orthodoxy 1750–1850 (London: Croom Helm, 1987); Roger Cooter (ed.), Studies in the History of Alternative Medicine (Basingstoke: Macmillan Press, 1988); Norman Gevitz (ed.), Other Healers: Unorthodox Medicine in America (Baltimore: Johns Hopkins University Press, 1988); Phillip A. Nicholls, Homeopathy and the Medical Profession (London: Croom Helm, 1988). 4. T. J. Hinrichs offers an interesting perspective on the practitioner-historian in relation to the history of non-Western and cross-cultural medicine in ‘New Geographies of Chinese Medicine’, Osiris, 13 (1998), 287–35. 5. See, for example: Joseph S. Alter (ed.), Asian Medicine and Globalization (Philadelphia: University of Pennsylvania Press, 2005); Don Bates (ed.), Knowledge and the Scholarly Medical Traditions (Cambridge: Cambridge University Press, 1995); Roberta Bivins, Acupuncture, Expertise and Cross-Cultural Medicine (Basingstoke: Palgrave, 2000); eadem, Alternative Medicine? A History (Oxford: Oxford University Press, 2007); Mark Harrison, ‘Medicine and Orientalism: Perspectives on Europe’s Encounter with Indian Medical Systems’, in Biswamoy Pati and Mark Harrison (eds), Health, Medicine and Empire: Perspectives on Colonial India (New Delhi: Orient Longman, 2001), 37–87; Charles Leslie and Allan Young, Paths to Asian Medical Knowledge (Berkeley: University of California Press, 1992); Lu Gwei-djen and Joseph Needham, Celestial Lancets: A History and Rationale of Acupuncture and Moxa (Cambridge: Cambridge University Press, 1980). For a lucid introduction to the complex transmissions pathways between the Graeco-Roman, Arabic-Islamic, and European medical traditions, see Lawrence Conrad, Michael Neve, Vivian Nutton, Roy Porter, and Andrew Wear, The Western Medical Tradition (Cambridge: Cambridge University Press, 1995). 6. David Arnold and Sumit Sarkar, ‘In Search of Rational Remedies: Homoeopathy in Nineteenth-Century Bengal’, in Waltraud Ernst (ed.), Plural Medicine, Tradition and Modernity, 1800–2000 (London: Routledge, 2002), 40–57; Gary Hausman, ‘Making Medicine Indigenous: Homeopathy in South India’, Social History of Medicine, 15 (2002), 303–22; Christian Hochmuch, ‘Patterns of Medical Culture in Colonial Bengal, 1835–1880’, Bulletin of the History of Medicine, 80 (1) (2006), 39–72; Helen Lambert, ‘Plural Traditions? Folk Therapeutics and “English” Medicine in Rajasthan’, in Andrew Cunningham and Bridie Andrews (eds), Western Medicine as Contested Knowledge (Manchester: Manchester University Press, 1997), 191–211; Neshat Quaiser, ‘Politics, Culture and Colonialism: Unani’s Debate with Doctory’, in Pati and Harrison (eds), Health, Medicine and Empire, 317–55. 7. Among the honourable exceptions are Bridie J. Andrews,‘Tuberculosis and the Assimilation of Germ Theory in China, 1895–1937’, Journal of the History of Medicine and Allied Sciences, 52 (1) (1997), 114–57; eadem, ‘From Case Records to Case Histories: The Modernisation of a Chinese Medical Genre, 1912–1949’, in Elisabeth Hsu (ed.), Innovations in Chinese Medicine (Cambridge: Cambridge University Press, 2001), 324–36.

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8. Waltraud Ernst, ‘Plural Medicine, Tradition and Modernity: Historical and Contemporary Perspectives: Views from Below and from Above’, in idem (ed.), Plural Medicine, 1–18. 9. M. N. Pearson, The World of the Indian Ocean, 1500–1800: Studies in Economic Social and Cultural History (Burlington: Ashgate, 2005); Roderich Ptak, ‘China and the Trade in Cloves, circa 960–1435’, Journal of the American Oriental Society, 113 (1993), 1–13. 10. Christopher Beckwith, ‘The Introduction of Greek Medicine into Tibet in the Seventh and Eighth Centuries’, Journal of the American Oriental Society, 99 (1979), 297–313; Elisabeth Finckh, Foundations of Tibetan Medicine, vol. 1. (London: Watkins, 1978); Andrew Edmund Goble, Kenneth R. Robinson, and Haruko Wakabayashi (eds), Tools of Culture: Japan’s Cultural, Intellectual, Medical, and Technological Contacts in East Asia, 1000s–1500s (Ann Arbor: Association for Asian Studies, 2009); Wai-ming Ng, ‘The I Ching in Tokugawa Medical Thought’, East Asian Library Journal, 8 (1998), 1–26; Miyasita Saburo, ‘A Link in the Westward Transmission of Chinese Anatomy in the Late Middle Ages’, Isis, 58 (1967), 486–90; G. R. Tibbetts, A Study of the Arabic Texts Containing Material on South-East Asia (Leiden: Brill, 1979); Paul Unschuld, Medicine in China: A History of Ideas (Berkeley: University of California Press, 1985). 11. Carole Hillenbrand, The Crusades, Islamic Perspectives (Edinburgh: Edinburgh University Press, 1999); Marcus Milwright, ‘Balsam in the Medieval Mediterranean: A Case Study of Commodity and Information Exchange’, Journal of Mediterranean Archaeology, 14 (1) (2001), 3–23; Piers D. Mitchell, Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon (Cambridge: Cambridge University Press, 2004); Carla Rahn Phillips, ‘Spanish Medicine before the Eighteenth Century’, Journal of the History of Medicine and Allied Sciences, 35 (1980), 75–80; Peter E. Pormann and Emilie Savage-Smith, Medieval Islamic Medicine (Edinburgh: Edinburgh University Press, 2007); A. I. Sabra, ‘The Appropriation and Subsequent Naturalization of Greek Science in Medieval Islam: A Preliminary Statement’, History of Science, 2 (1987), 223–43; Nancy G. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago: University of Chicago Press, 1990). 12. Michael Adas, Machines as the Measure of Men: Science, Technology, and Ideologies of Western Dominance (Ithaca: Cornell University Press, 1989). 13. Bivins, Alternative Medicine? For an exploration of the interpretive differences between these systems, however, see Shigehisa Kuriyama, The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine (New York: Zone Books, 1999). 14. ‘A Catalogue of Such Foreign Plants as Are Worthy of Being Encouraged in the American Colonies, for the Purposes of Medicine, Agriculture, and Commerce’, Transactions of the American Philosophical Society, 1 (Jan. 1, 1769–Jan. 1, 1771), 255–66: Jorge CanizaresEsguerra, ‘Iberian Colonial Science’, Isis, 96 (2005), 64–70; Ronald L. Numbers (ed.), Medicine in the New World: New Spain, New France, and New England (Knoxville: University of Tennessee Press, 1987). 15. David Arnold (ed.), Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900 (Amsterdam: Editions Rodopi, 1996). 16. Interesting work has been done on this topic in relation to China and Japan; see H. Beukers, A. M. Luyendijk-Elshout, M. E. van Opstall, and F. Vos, Red-Haired Medicine: Dutch-Japanese Medical Relations (Amsterdam/Atlanta: Rodopi 1991). The Chinese context for such exchanges can be gathered from James Hevia, Cherishing Men from Afar: Qing Guest Ritual and the Macartney Embassy of 1793 (Durham, NC: Duke University Press, 1995); David E. Mungello, Curious Land: Jesuit Accommodation and the Origins of Sinology (Honolulu: University of Hawaii Press, 1989); Hugh Shapiro, ‘The Puzzle of Spermatorrhea in Republican China’, Positions, 6 (3) (1998), 551–96.

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17. Bivins, Acupuncture; eadem, Alternative Medicine?; and Harold Cook, Matters of Exchange: Commerce, Medicine, and Science in the Dutch Golden Age (New Haven, CT: Yale University Press, 2007). 18. Isaac Vossius, for example, enthused about acupuncture in 1685, but described it as ‘that perforation of all parts of the body, which they do even of the very brain itself, transfixing it from one side of the head to the other with a metal bodkin a cubit in length or longer’. 19. There has been considerable contestation about some of them. See, for example: Edward Kajdański, ‘Michael Boym’s “Medicus Sinicus”’, T’oung Pao, second series, 73 (4/5) (1987), 161–89. 20. On translation of Japanese specifically, see P. F. Kornicki, ‘European Japanology at the End of the Seventeenth Century’, Bulletin of the School of Oriental and African Studies, 56 (3) (1993), 502–24. 21. Londa L. Schiebinger Plants and Empire: Colonial Bioprospecting in the Atlantic World (Cambridge, MA: Harvard University Press, 2004); Londa Schiebinger and Claudia Swan (eds), Colonial Botany: Science, Commerce, and Politics in the Early Modern World (Philadephia: University of Pennsylvania Press, 2004). 22. James Whorton documents some of these alliances in Nature Cures: The History of Alternative Medicine in America (New York: Oxford University Press, 2002), and highlights the epistemological and conceptual continuities between many nineteenth-century ‘alternatives’. 23. Philippa Martyr, Paradise of Quacks: An Alternative History of Medicine in Australia (Sydney: Macleay Press, 2002); Haiming Liu, ‘The Resilience of Ethnic Culture: Chinese Herbalists in the American Medical Profession’, Journal of Asian American Studies, 1 (2) (1998), 173–91. 24. See Liu, ‘Chinese Herbalists’, 186–7. As yet, there has been no comparative study (and no book-length account) of these cross-cultural medical communities. 25. Nicholls, Homeopathy; Abraham Flexner, Medical Education in the United States and Canada (New York: Carnegie Foundation, 1910), 156–7. 26. For the historian’s perspective, see Norman Gevitz, Andrew Taylor Still and the Social Origins of Osteopathy (Basingstoke: Macmillan, 1988); John S. Haller, Jr., The People’s Doctors: Samuel Thomson and the American Botanical Movement, 1790–1860 (Carbondale: Southern Illinois University Press, 2000); Ronald L. Numbers, Prophetess of Health: A Study of Ellen G White (New York: Harper and Row, 1976). 27. Nicholls, Homeopathy; Martin Kaufman, Homeopathy in America: The Rise and Fall of an American Heresy (Baltimore: Johns Hopkins University Press, 1971); John S. Haller, Jr., The History of American Homeopathy: The Academic Years, 1820–1935 (New York: Pharmaceutical Products Press, 2005). 28. Alison Winter, Mesmerized: Powers of Mind in Victorian Britain (Chicago: University of Chicago Press, 1998); Rennie Schoepflin, Christian Science on Trial: Religious Healing in America (Baltimore: Johns Hopkins University Press, 2003). 29. See also Carsten Timmermann, ‘Constitutional Medicine, Neo-Romanticism and the Politics of Anti-Mechanism in Interwar Germany’, Bulletin of the History of Medicine, 75 (2001), 717–39. 30. Martin Dinges (ed.), Patients in the History of Homoeopathy (Sheffield: European Association for the History of Medicine and Health, 2002); Anne Hilde van Baal, In Search of a Cure: The Patients of the Ghent Homoeopathic Physician Gustave A. Van den Berghe (1837–1902) (Rotterdam: Erasmus, 2008). 31. Bynum and Porter (eds), Medical Fringe and Medical Orthodoxy; Cooter (ed.), Studies in the History of Alternative Medicine, 1750–1850; Gevitz (ed.), Other Healers.

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32. Marijke Gijswijt-Hofstra, Hilary Marland, and Hans de Waardt (eds), Illness and Healing Alternatives in Western Europe (London: Routledge, 1997); Robert Jütte, Motzi Eklöf, and Marie C. Nelson (eds), Historical Aspects of Unconventional Medicine: Approaches, Concepts, Case Studies (Sheffield: European Association for the History of Medicine and Health, 2001). 33. Julian Roebuck and Robert Quan, ‘Health-Care Practices in the American Deep South’, in Roy Wallis and Peter Morley (eds), Marginal Medicine (New York: Free Press, 1976), 141–61, at 141. 34. For a range of approaches, see Roy Porter (ed.), The Popularization of Medicine 1650–1850 (London: Routledge, 1992). 35. Mike Saks, Alternative Medicine in Britain (Oxford: Clarendon Press: 1992); Sarah Cant and Ursula Sharma (eds), Complementary and Alternative Medicine: Knowledge in Practice (London: Free Association Books, 1996). 36. Whorton, Nature Cures; Hans Baer, Biomedicine and Alternative Healing Systems in America: Issues of Class, Race, Ethnicity, and Gender (Madison: University of Wisconsin Press, 2001). 37. Naomi Rogers, An Alternative Path: The Making and Remaking of Hahnemann Medical College and Hospital of Philadelphia (New Brunswick NJ: Rutgers University Press, 1998). 38. John S. Haller, Jr., A Profile in Alternative Medicine: The Eclectic Medical College of Cincinnati, 1845–1942 (Kent, OH: Kent State University Press, 1999). 39. John S. Haller, Jr., Kindly Medicine: Physio-Medicalism in America 1836–1911 (Kent, OH: Kent State University Press, 1998). 40. Anne Taylor Kirschmann, ‘Adding Women to the Ranks, 1860–1890: A New View with a Homeopathic Lens’, Bulletin of the History of Medicine, 73 (3) (1999), 429–46; Naomi Rogers, ‘Women and Sectarian Medicine’, in Rima D. Apple (ed.), Women, Health, and Medicine in America: A Historical Handbook (New York: Garland, 1990), 281–310. 41. William McNeill, Plagues and Peoples (New York: Doubleday, 1976). 42. Lu and Needham, Celestial Lancets. The 2002 Routledge edition of this volume includes an excellent historiographical introduction by Vivienne Lo, which analyses subsequent developments in the English- and Chinese-language literatures on acupuncture side by side. See also Hinrichs, ‘New Geographies of Chinese Medicine’. 43. Don Bates, ‘Why Not Call Modern Medicine “Alternative” ? ’, Annals of the American Academy of Political and Social Sciences, 583 (2002), 12–28.

Select Bibliography Alter, Joseph S. (ed.), Asian Medicine and Globalization (Philadelphia: University of Pennsylvania Press, 2005). Bates, Don (ed.), Knowledge and the Scholarly Medical Traditions (Cambridge: Cambridge University Press, 1995). Bivins, Roberta, Alternative Medicine? A History (Oxford: Oxford University Press, 2007). Cunningham, Andrew, and Bridie Andrews (eds), Western Medicine as Contested Knowledge (Manchester: Manchester University Press, 1997). Dinges, Martin (ed.), Patients in the History of Homoeopathy (Sheffield: European Association for the History of Medicine and Health, 2002). Ernst, Waltraud (ed.), Plural Medicine, Tradition and Modernity, 1800–2000 (London: Routledge, 2002).

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Gijswijt-Hofstra, Marijke, Hilary Marland, and Hans de Waardt (eds), Illness and Healing Alternatives in Western Europe (London: Routledge, 1997). Martyr, Philippa, Paradise of Quacks: An Alternative History of Medicine in Australia (Sydney: Macleay Press, 2002). Porter, Roy, Quacks: Fakers and Charlatans in English Medicine (Stroud: Tempus, 2000). Rogers, Naomi, An Alternative Path: The Making and Remaking of Hahnemann Medical College and Hospital of Philadelphia (New Brunswick, NJ: Rutgers University Press, 1998). Saks, Mike, Alternative Medicine in Britain (Oxford: Clarendon Press, 1992). Schiebinger, Londa L., Plants and Empire: Colonial Bioprospecting in the Atlantic World (Cambridge, MA: Harvard University Press, 2004). Whorton, James, Nature Cures: The History of Alternative Medicine in America (New York: Oxford University Press, 2002).

chapter 33

oral testimony and the history of medicine k ate f isher

In 1991, Paul Thompson lamented the limited use of oral history by historians of medicine and urged more scholars to make use of it.1 In Britain, initially at least, oral histories that considered topics related to health and disease were not conducted by medical historians but by social historians, gender historians, and local historians, and outside the academy by librarians, museum curators, and reminiscence groups.2 In 1976, Raphael Samuel drew the attention of medical historians to the important work of local history groups, arguing that the recent publication of a series of transcripts remembering the interventions of Dr Jelley, a discredited doctor/abortionist between 1910 and 1930, was more informative about ‘popular medicine, and the ways in which illness was coped with in the home, than volumes of Medical Officer of Health reports’.3 Also in 1991, Nancy Tomes documented the richer trajectory of American oral histories of health and medicine. Since the 1960s, she revealed, health care professionals, fuelled by the recognition that medical practice had been transformed by biomedical culture in the twentieth century, were quick to realize the value of oral history in documenting this change.4 Since the early 1990s, however, the historiographical landscape has transformed. As the history of medicine has responded to a greater focus on social history, the rise of cultural history, the attack on Whiggish histories of progress, and a desire to uncover the patient’s (as well as the doctor’s) perspectives on health and disease have all fostered interest in oral history methodology. In Britain, the Wellcome Trust has been a particular champion of oral history and responded to the proliferation of students planning to use oral history by establishing and funding a training course in oral history for historians of medicine. In 1990, the Trust set up the Wellcome Witnesses to Twentieth Century Medicine series, which seeks to bring together ‘several people associated with a particular set of circumstances or events . . . to discuss, debate, and even disagree about their memories’.5 Since then the transcripts of thirty-eight seminars covering a huge range of topics such as the politics of breastfeeding, the 1967 foot and

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mouth outbreak, the clinical treatment of haemophilia, and medical education in Africa since 1945 have been published. A similar series of witness seminars has recently been set up by the Centre for the History of Medicine in the University of Glasgow. Below I shall survey the historiographical trends in medical history that have fostered the rise in the use of oral history since 1990. All these different approaches serve to bring individual experiences and human agents into the historical frame, humanizing our understanding of the national and international institutions, professions, governments, and organizations that shape medical history. Oral history reveals the clinicians behind changing medical treatments and the personal experiences behind patient populations or epidemiological trends. I shall argue, however, that oral history needs to do more than merely present the ‘individual perspective’; rather, it should aim to chart and explore the relationship between the structures of medicine and human experience. Oral history does not provide unmediated access to individuals’ experiences but rather to the ways in which individuals understand their experiences in dialogue and interaction with a range of competing cultural messages. Moreover, oral testimony does not document the past, but is an individual’s interpretation of it; historians therefore need to interrogate it as such, exploring why people remember in certain ways, what is forgotten or mis-remembered, and what such memories mean for the present. Some oral historians have used reminiscence directly in addressing contemporary issues in health care. Some have fruitfully explored the ways in which reminiscence work in care homes can be therapeutically beneficial.6 Others have used interviews to develop better treatment strategies based on a clearer understanding of the context of patients’ lives and their experiences of illness.7 Sanjiv Kakar, for example, used life story interviews to develop a leprosy treatment strategy that was tailored to particular communities’ beliefs, social structure, and experiences.8 For reasons of space, however, this chapter will not explore these clinical or therapeutic uses of oral history.

Professional perspectives Many early oral histories of medicine sought to explore biomedical developments through the voices of those professional doctors, scientists, and practitioners who had been involved in major breakthroughs or changes. Such interviews with individual players in the field of medicine pioneered versions of medical history that broke down the focus on institutions and organizations—pharmaceutical firms, professional associations, government departments—and explored the actions and views of the individuals who made up these groups. These oral histories allowed the individual agents behind the structural frameworks to enter the historical narrative.9 As Nancy Tomes comments, ‘oral history is best at revealing individuals’ feelings, thoughts and responses’ and she champions the ability of oral history to expose ‘the historian . . . to a more familiar and believable world of human beings’ and to ‘go beyond charting bio-medical successes’.10

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Interesting work has been done on the interaction between medical professionals and the everyday clinical experiences of the vast range of health providers: doctors, surgeons, pharmacists, herbalists, medical missionaries, nurses, midwives, health visitors, and so on.11 Margaret Shkimba and Karen Flynn explore the contrasting experiences of Caribbean and British nurses in Canada and the United Kingdom, highlighting the different medical cultures and professional hierarchies in the different countries in which they worked.12 Alan Weisse’s use of interviews with sixteen cardiac clinicians and academics provides a good example of the advantages of oral testimony in charting the human interactions behind scientific and clinical progress.13 Such material is absent from archival sources since modern medical practice is surprisingly poorly documented: relatively few practitioners or professionals reflect on their careers; correspondence has dwindled with the growth of telephone and more recently electronic forms of communication; and case notes are routinely destroyed, as is much of the huge volume of clinical paperwork that institutions do not have the space, time, or money required to collect, store, or catalogue. While it might be feared that oral history interviews with elites or professionals enable and promote the self-aggrandising narrative,14 far from being triumphalist or supportive of Whig narratives of medical progress oral histories with health professionals are often self-critical and ambivalent.15 A Wellcome Witness Seminar on the reduction of perinatal morbidity and mortality revealed that clinical reluctance to change clinical practice in response to scientific breakthroughs owed much to professional rivalries (between paediatricians and obstetricians) and distrust of research emanating from medical research laboratories outside Britain or the United States.16 Ronald Bayer and Gerald Oppenheimer’s interviews with seventy-six of the ‘first generation’ of AIDS doctors in the United States drew upon the methodological insights developed by Alessandro Portelli in putting the speakers’ subjective memories and the meanings ascribed to events and experiences at the centre of the analysis. They determinedly avoided a ‘hagiographical’ account and did not use oral history to chart clinical developments or the trajectory of medical responses. Rather the interviews were used to explore doctors’ experiences of the epidemic, not simply what they did, but what they thought they were doing, what it meant to them and how they came to terms with events in the early history of AIDS.17 Similarly sophisticated is Graham Smith’s work on the changing history of communication between general practitioners and consultants in Britain since 1945, which focuses on the politics of referral and the tensions and rivalries in these professional relationships. He does not merely focus on the players’ recollections of such relationships, but analyses the dialects of their reminiscence as a means of elucidating the tensions and points of agreement between key players and their attitudes towards one another. Language is shown to have been critical to understanding the collective identities of historical actors and the dynamics of professional inclusion, exclusion, respect, and hierarchy.18 Occasionally, innovative oral histories with medical professionals make sophisticated analytical use of the post hoc revisions of clinical narrators. In a justly famous history of virology based on an interview with Tom Rivers, Saul Benison uncovered how Rivers

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fabricated some of the details behind key professional rivalries. Rather than dismissing his witness as unreliable, Benison used this testimony to better understand the role played by Rivers, his professional identity, and the personal and institutional dynamics of twentieth-century virology.19 Such sophisticated analyses of oral testimony with medical professionals, however, remain relatively rare. The Wellcome Witness series, for example, generally remains committed to collecting key players together in order to produce a consensual and factually accurate version of past events, rather than to explore the dynamics of contested versions of what happened. For example, strangely absent from the witness seminar on the changing culture of maternal care was any demonstration of the conflict and rivalry between midwives and obstetricians, presumably because the selected participants were an elite group of like-minded professionals and not a cross-section of maternal care professionals.20 Witness seminars provide rich, often riveting, insights into the complex interactions and processes behind medical research and development, but do not exploit the differences in participants’ memories or what such conflicts in memory tell us about the significance of the past for the present.

Patient narratives It is in fleshing out the patient experience that oral history has proved a particularly useful tool for historians.21 Early advocates of oral history championed it as a method that, above all, provided access to the voices and experiences of those usually absent from the documentary record. Much of this work sought simply to uncover the hidden voice of the patient, seeing such perspectives as providing a contrast with that of the medical profession. It is through such testimony, many argue, that we can go beyond clinical categories to hear what the bodily experience of ill-health was or to uncover the complex personal impact of disease. Indeed some effective oral histories consist merely of lightly edited transcripts of patients’ recollections.22 The patient can be difficult to find in documentary sources and even where their voices might be found, in the material gathered for research purposes, in clinic records or case files, increasingly such material is not archived. For example, the National Health Service (NHS) has strict guidelines especially since the Data Protection Act of 1989, which specifically prohibits the archiving of health records for historical purposes: ‘If such records are no longer required for the purposes of providing care, then they should not be retained.’23 Moreover, oral history provides access to the voice of the patient outside a clinical setting; a perspective on disease and ill-health that medical documents could not hope to provide. Beyond clinical descriptions, oral history supplements such understandings with details of the ways in which individuals live with disease and conceptualize their own symptoms, diagnoses or prognosis.24 Kathryn Montgomery Hunter has explored the differences between the medical narrative of the case history and the illness narrative told by the patient.25 Mary Jo Festle’s work with the recipients of lung transplants is a good example of the use of oral history to provide access to personal

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kate fisher

understandings of the outcome and experience of treatment, which she contrasts with that of medical professionals: oral history respondents, she suggests, ‘provide their own definitions of quality of life, determine for themselves in what areas they are doing well or need help, and assign their own values to the aspects of life they consider most important.’ This testimony provides historians with the details of the experience—the daily routine, the precise effects of treatment and the ways in which illness is integrated into the rich fabric of lived lives.26 Sarah Leavitt’s work on the impact of home pregnancy tests is an excellent example of the ways in which interview material can illuminate an apparently trivial ‘revolution’ in medical technology by revealing the dramatic impact it had on individual women’s (and men’s) relationship to their reproductive health, their understanding and experience of pregnancy, and their interaction with the medical profession.27 Similarly, Glenn Smith, Annie Bartlett, and Michael King uncovered powerful narratives recording the opinions and experiences of both patients and therapists involved in the ‘treatment’ of homosexuality in the 1950s.28 One particularly interesting strand of this approach to the history of medicine uses oral history to uncover lay conceptions of illness in contrast to those of the medical profession. Such historians draw upon the approaches of social history to move the history of medicine away from the narrow perspective of the doctor and patient to the larger social and cultural sphere in which health is maintained or ill-health managed. Here it is health in the home, the workplace, and the community that is at the centre of the analysis. In 1982, Jocelyn Cornwell published her study of lay attitudes towards health and the experiences of being ill in Bethnal Green and revealed that individuals often produced contradictory accounts. She distinguished between the ‘public’ versions of their lives that interviewees told at first and the private stories that often emerged once a deeper relationship of trust had developed during the interview. These private narratives were often less supportive of prevailing medical theory or practice.29 More recently, Lucinda McCray Beier has used the testimony of 239 men and women born between 1872 and 1958 to chart individual responses to the dramatic changes in the delivery of health services and the transformations of biomedicine during the twentieth century. She explores how working-class families responded to such transformations, how individuals understood illness and health risks, how they responded to various interpretations of disease, and how they decided what remedies to try or whom to consult in times of need. There was no quick conversion to the gospel of germ theory, the domestic science of disinfection and hygiene, or the avoidance of contagion through isolation. Beier charts how, only gradually and primarily for financial reasons, and especially after the creation of the NHS in 1948, biomedicine became the first rather than the last port of call in times of medical need.30 Ali Haggett has looked at the stories of women who experienced depression, anxiety, and stress during the 1950s and 1960s: the drugs they took, how they felt about them, and how such medication was integrated into their roles as wives and mothers.31 Simon Guest has explored how individuals lived with tuberculosis in Ireland in the 1940s and 1950s, documenting the continued stigma attached to the affliction and the range of ‘home cures’ that continued to be adopted, even within sanatoria.32

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Colonial historians have also seen oral history as a means of accessing the experience of health from the perspective of those whose voices do not appear in the archival sources and to ‘resurrect indigenous modes of thought and representation’.33 One such example is Julie Livingston’s investigation of Botswanan experiences of medicine in the context of the changing health trajectories following the interventions of colonial medical practice. The past fifty years has seen age at puberty fall and the earlier onset of some age-related afflictions such as stroke. She explores indigenous responses to these changes and the ways they integrated their epistemological universe with that of Western biomedicine. Rather than adopting a Western understanding of the changing life cycle, which, for example, linked the falling age at puberty with increased health and better nutrition, many Bostwanese saw such changes as indicative of the ways in which colonial medical practice and new ways of life had created bodies that were out of balance with nature. Earlier onset of puberty was frequently interpreted as an alarming indication of an acceleration in the speed by which individuals used and exhausted their ‘life force’, creating bodily weakness and subverting the harmonious relationship between the body and natural rhythms. Here oral history provides rare access to local interpretations of health and a new window into individuals’ epistemological experiences of their bodies and its workings.34 Some of the best explorations of patients’ perspectives use oral testimony to examine the relationship between the experience of illness and patients’ social and personal identities. Such studies can look at the long-term experience of illness, and the complex and wide-ranging effect of disease on people’s lives, relationships, and life trajectories. Such narratives also highlight differences in medical and individual understandings of the nature of particular diseases and illustrate the impact of ill-health beyond clinical categories. Arthur McIvor and Ronald Johnston’s recent work on the occupational health of miners, for example, focuses on the long-term experiences of victims of pneumoconiosis, asbestosis, and mesothelioma and explores the variety of ways in which such problems have affected individuals’ lives: ‘premature death, bodily damage, and deterioration, trauma, social exclusion, and loss of masculinity’. In seeking, in particular, to revise the history of occupational disease which focuses on workers as ‘passive victims’ of industrial exploitation, they have focused on miners’ mentalities and identities.35 They have charted the ways in which miners’ self-identities framed their responses to ill-health, and in turn the effect of occupational diseases on miners’ self-understandings. Miners are shown to have understood their own bodies in very different ways to the medical profession: miners’ responses to illness or the threat of disease reflected particular macho cultures; and codes of masculinity meant that it was unmanly to avoid dangerous work practices. Moreover, such beliefs and identities had a particular impact on the experiences of disease as men found themselves excluded from active life in a maledominated environment and confined in a traditionally female-dominated sphere of the home.36 In this work the use of oral history to uncover the patient perspective goes beyond a narrow focus on patient experiences and looks more deeply at the ways in which health and illness are related to identity formation. Wendy Rickard’s work on HIV and AIDS provides another good example of this approach as she explores the recomposition of individuals’ personal identities following diagnosis.37 Such questions

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kate fisher

could be profitably asked of other studies, such as the investigation of the psychiatric treatments offered to British homosexuals in the 1950s conducted by Glenn Smith and his team. Published primarily in medical and psychiatric journals, the interviews with these men have been used to demonstrate the mistakes of medicine in the past and provide lessons for the future. This work has not been used to address debates about the transformation in homosexual sex-identities during the twentieth century which dominate the historical literature, nor does it explore the complex relationship between medical theories of homosexuality and individuals’ perceptions of themselves.38 The history of mental health has proved particularly rich for historians interested in uncovering the patient’s perspective. Drawing upon both the legitimization of the voices of the ‘mad’ that emerged following the anti-psychiatry movement of the 1960s and the recognition that the documentation produced by psychiatrists and other clinical voices should be viewed as mechanisms through which professionals exerted power and control, attempts to hear the views of the ‘mad’ have been at the centre of many recent approaches to the history of psychiatry and mental illness.39 Given the methodological problems in listening to the silent voices of those in mental institutions, whose lives are primarily documented in texts produced by medical professionals and used as evidence in support of a particular diagnosis or clinical assessment, historians have championed the use of oral history as a means of uncovering the views of those deemed too ill or irrational to be documented on their own terms.40 These historians have used oral history to present revisionist histories of asylum life. Rebecca Fido and Maggie Potts’ interviews with long-term residents of institutions for the mentally deficient highlight precisely those aspects of the history of such institutions only obliquely recorded in institutional records: the trauma of certification and admission; the fear and bewilderment upon being incarcerated; the emotional and social experiences of the regime; and the care and treatments provided.41 Such material enables historians to contrast the medical interpretations of an individual’s mental state with the patient’s own view. As one resident commented: ‘It’s not true what was written down! They did it just to keep us locked up, so that people would think we’re mental!’42 By contrast, Diana Gittins’s work has challenged the idea that asylum life was invariably isolating and alienating and revealed the extent to which many individuals remembered mental institutions as places of rich and compassionate social interactions. Notwithstanding the instances of mercurial and experimental treatments, she documented the ways in which patients saw the asylum as a companionate community and safe haven and retrospectively supported their own involuntary incarceration.43 Yet, it is naïve to see the voices of patients, or the accounts of experiences of health and disease, as distinct from or different to those of the clinicians. The patient’s perspective cannot be straightforwardly contrasted with that of the clinical or regarded as providing a separate and alternative viewpoint on ill-health. Geoffrey Raume is typical, but mistaken, in concluding that oral history can provide patient experiences ‘free from the constraints of “official” medical interpretations’.44 Historians of colonial medicine have been rather quicker to realize, in the words of Packard, that ‘oral history cannot resurrect indigenous voices as pristine entities, but as forms of knowledge that are

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shaped by, and reflective of, the legacy of the colonial era’.45 Thus, oral history is better conceptualized as providing us with access to the intersection between medical and other voices on disease and to the ways in which individuals process and make sense of the medical diagnoses and clinical categories through which information about their bodies, pains, and symptoms are explained to them, in conjunction with their own experiences and the views of others around them. The patient is faced with a variety of ‘rhetorics’ that structure and constitute their own experience and oral historians studying the accounts of both patient and practitioner need to explore in greater depth the complexities of healing narratives or stories of illness.46 There is no simple divide in the rhetorics of illness; rather all illness accounts reflect a dialogue between agents as each seeks to integrate their different epistemological standpoints, the different ways which they have of observing and experiencing disease, and the different theories or understandings of the body and its mechanisms. The analysis of this interplay remains undeveloped and is a crucial area for future oral history research. Kerry Davies’ work on the history of mental health is unusual in recognizing that the patient’s perspective provides historians with access to the ways in which individuals viewed themselves as patients and made sense of their experiences in dialogue with the views and assessments of themselves provided by others. Her oral history shows how those involved in the mental health system ‘negotiated definitions of their illnesses’ and developed acceptable narratives to understand their experiences and treatments in ways informed by both lay and psychiatric discourses of ‘madness’. She shows how charting the shifting framework of patients’ narratives provides insight into the changing cultural and medical conceptualizations of mental illness and the shifting relationships between patients and health care professionals.47 Literature on the changing history of childbirth provides another good example. Oral histories of women’s experiences of birth have been seen to provide access to the ‘authentic’ and ‘ignored’ voices of women.48 Feminist historians have seen women’s voices as key to revealing the costs for women of the increased medicalization of birth practices in the Western world, in which the clinical assessment of risk, safety, and pain relief has obscured the different criteria drawn upon by women to assess the success of the birthing process.49 However, as is increasingly recognized by literary scholars who have studied women’s birth stories, such narratives are not unmediated versions of marginalized subjectivities, but instead women’s own experiences of birth are powerfully affected by a range of contradictory discourses. As Tess Cosslett recognizes, a woman’s experiences of birth are shaped by the stories she has heard and what she chooses to believe.50 How women experienced birth in the context of the prevailing debates, cultural practices, and contestations about birth is a potentially fascinating area of study. Some initial work in this area has begun. Angela Davis has uncovered the ways in which women giving birth in the 1950s often demonstrated their commitment to motherhood as the key to femininity by downplaying the difficulties, complications, or discomforts they experienced during pregnancy and birth.51 Future oral history projects might investigate changing attitudes towards pain relief, the place of birth, who attends the birth, and what medical interventions are appropriate in what circumstances alongside the changing

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views of the range of medical, familial, and media opinions to which each woman is exposed.

Ethics and data protection Oral historians have long been aware of the complex ethical issues raised by their methodology and such debates have led to the production of elaborate guidelines in the fields of oral history, ethnography, and sociology. However, historians of medicine can find themselves caught between the different ethical conventions demanded by the regulators of medical research and those deemed appropriate to social research including oral history.52 Indeed, the tensions between sociological approaches to the ethics of data collection and those of health research are increasingly apparent.53 One recent exploration of the issues attacked regulators for ‘acting on the basis of bio-medically driven arrangements that make little or no sense to social scientists’, while another wondered whether her previous interviews with sex workers would have been permitted under the emerging contemporary ethics review boards.54 For British historians of medicine considerable criticism has been targeted at the inflexible expectations of NHS ‘Research Ethics Committees’ whose approval is necessary for any research involving NHS staff or patients (past or present), patient records, or NHS premises.55 In America, academic historians have objected to the regulation of their research projects by Institutional Review Boards (IRBs), ‘constituted entirely of medical and behavioural scientists, who have little understanding of the principles and protocols of humanistic inquiry’.56 Despite an agreement in the early 2000s that the federal regulations designed to protect research subjects from physical or mental harm were not relevant for oral historians the use of IRBs to monitor oral historians’ research continues.57 There are three key areas where biomedically driven ethical conventions cause difficulties for historians of medicine conducting oral history interviews: first in obtaining informed consent; second in negotiating issues to do with anonymity and privacy; and third in establishing who can use the data and in what circumstances. The need for potential participants to be fully informed of the research and able to decide voluntarily whether to take part would appear uncontroversial and obvious. Yet some regulators expect researchers to adopt elaborate, formal procedures for informing potential participants of the research questions, the purpose of the research, the methods to be used, the process involved, and the range of possible outcomes that are often inappropriate in the context of communicating about historical matters to elderly potential participants.58 Consent forms can be obtrusive, intimidating, and complicated documents, requiring detailed and careful explanation and requiring participants to have high levels of literacy, linguistic ability, and social confidence; some regulatory bodies require the signing of multiple documents. Moreover, such documents can encourage a relationship of mistrust and suspicion and often overestimate the potential risks in a manner that is alarming rather than informative. Signing a consent form prior to an

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interview taking place often means that participants are liable to feel committed to the process and disempowered from exercising their right to withdraw or to renegotiate the terms of their involvement.59 Moreover, in oral history research, unlike the collection of quantitative data, full information about the project cannot be provided in advance, since research questions change as the project develops and as key themes emerge and hypotheses are formed; without a clear pre-defined set of questions a full assessment of the potential outcomes or risks of the project cannot be made and consent should therefore be established as an ongoing process.60 These difficulties affect many projects, yet it is the rigid and bureaucratic structures of biomedically driven ethics committees, which are often reluctant to authorize the use of alternative methods for obtaining informed consent, that has disadvantaged some oral history projects. In 2000, a multi-centre Research Ethics Committee (REC) suggested that in recruiting elderly participants to an oral history project exploring experiences of marriage and sexuality in the twentieth century general practitioners should be used as an initial point of contact for potential participants and employed to provide them with information about the project, to discuss the advantages of taking part, and to witness the signing of consent forms prior to any interviews taking place. Although designed to protect participants, to ensure the project was perceived as legitimate and respectable and to provide emotional support to potential respondents during or after the process, in fact the use of general practitioners in this context would have been disempowering and disadvantageous. The REC was eventually persuaded that it would be inappropriate to use health professionals as gatekeepers for historical research not designed to have health benefits now or in the future and that using doctors in this fashion would have placed subtle pressure on potential respondents to cooperate. The assumption in most institutional ethics committees is that all research participants should be anonymous. Yet the requirement that respondents sign consent forms has the potential to compromise individuals’ rights to anonymity and creates a confusion that many find alarming. Moreover, there are many instances in which anonymity is not desirable, appropriate, or possible. Institutional ethics committees’ insistence on confidentiality is inappropriate when interviewees are public figures whose testimony is on the record and whose roles and status in any case make anonymity impossible. Many other interviewees wish to be named and the desire to have their lives recorded can be a motivating factor in agreeing to be interviewed.61 Although in some instances respondents’ wishes to have their testimony used anonymously are appropriate, in other cases participants are proud to take part in oral history projects and do not wish to have their contributions marginalized or unrecorded. Paul Weindling has drawn attention to the tensions between the historian’s role in memorializing and dignifying victims of Nazi medical experiments by identifying them and the policy of the Bundesarchiv that requires all personal data about victims to remain confidential.62 Oral historians face similar dilemmas. The tendency for testimony to be used anonymously can be seen as replicating the tendency of medical documents to collapse individuals into symptoms or diagnoses, rather than as restoring patients’ individuality, identity, and humanity.63 As Wendy Mitchinson argues, this ‘legal obligation . . . to protect the privacy of

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individuals’ enables us to ‘write the marginal into history’ only by ‘writing their names and faces out of it’.64 Furthermore, the ethical codes governing biomedical research generally require interview data to be destroyed once research is complete and findings have been disseminated through scientific publications. Such requirements are seen as necessary to protect those participating in medical research from having their data used for a purpose beyond the specific research agenda, but is complete anathema to historians, for whom the creation of an archivable body of material is often central to the purpose of conducting oral history interviews in the first place and for whom professional credibility rests on the availability of the source material for purposes of validation.65 In Britain, Kerry Davies was expected to destroy her interviews with mental health patients at the end of her PhD in 2002, and in 2006 in the United States Kathryn Staley found herself required, in a process described as ‘reinforcing the closet’, to destroy her interviews with members of a lesbian, gay, and bisexual group in a rural community to protect any third parties that might have been named by respondents. While the danger of archived interviews being used to research topics not originally envisaged, or specifically discussed with respondents, is of concern to the oral history profession, the centrality of using oral history to create historical evidence that can be of use beyond any specific research project as well a providing a mechanism for scholars to interrogate the findings of any project by returning to the original sources remains paramount.66 Yet, in discussing these tensions oral historians need to move beyond outraged invective against the regulatory authorities whose lack of commitment to the purposes of oral history research and whose unfamiliarity with the codes of ethical practice that have developed in the humanities and social sciences has impeded their research. Rather, it is increasingly important for the oral history profession to engage with regulatory bodies in constructing fluid and flexible ethical frameworks that accommodate the distinct professional aims and ethical concerns of oral history research.67

New directions Oral historians have increasingly become interested in the relationship between collective memories and individuals’ conceptions of their own lives. Such works look at how oral testimony tells us not only about personal experiences, but also about the memorial cultures that provide individuals with a historical framework for understanding their lives. Such a focus on the collective and social understandings of the past provides historians with greater insight into the socially dominant constructions of past events, the way stories about the past demonstrate individuals’ group identities, class identifications, or regional affiliations, and what the past means to the present. In the history of medicine, however, little work in this area has been done. Memories of diseases and ill-health have not been analysed as providing insight into collective memories nor dissected as carriers of social meaning and significance. Nor

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have the experiences of illness or attitudes towards health and medicine been investigated as part of a mechanism for understanding social, cultural, or national identities.68 Yet there is considerable scope for such work. What function do stories of health and illness play in the construction of collective identities and shared cultural understandings of the past? How are such identities established and revealed in oral history testimony? There are several obvious areas where such an approach would be insightful. For example, what do individuals’ accounts of the coming of the NHS in Britain and their experiences of health care since 1945 reveal about the place of the NHS in British national identity? A few historians have begun to recognize the manner in which the NHS has come to symbolize British values, focused, according to Helen Busby, around ‘a history of solidarity and shared risk’;69 oral history has the potential to enable historians to demonstrate, document, and dissect this relationship. Similarly, we might explore the function of stories of disease and ill-health in British and American stories of working-class life, and the role played by health issues in the construction of twentieth-century working-class cultural identities. It would also be profitable to use oral history to explore the collective understandings of major medical phenomena, incidents, and disasters.70 For example, how have the experiences of those involved in the Tuskegee syphilis trial in the United States been used as a metaphor for collective understandings of the history of racism, medical ethics, and medical power? How do these stories provide historians with evidence of the subsequent attitudes towards public health authorities, particularly among the black communities of North America?71 Lesley Diack has investigated the collective understandings of a typhoid epidemic in Aberdeen in 1964, which infected 500 people and was caused by a contaminated can of corned beef imported from Argentina. She was particularly interested in the ways in which three key ‘myths’ about the causes of the epidemic, reported by the media but subsequently revealed to be false, lived on in the folk memory of the incident and remained dominant in oral history testimony. She sees the persistence of these myths as indicative of the power of the media to construct stories that are believed whatever the truth of the matter turns out to be.72 Yet, surely there is more to these myths than the duping of society by media rumours. Oral history testimony might reveal why such rumours were seen as believable and what notions about the nature of Aberdeen and its residents they fitted into and fed. The study of the memory of such epidemics can do more than chart the ways in which the truth of an event can become distorted and that distortion memorialized. Oral history can instead highlight the deeper significance of such ‘false’ stories and the ways they are enmeshed in the wider community’s beliefs about disease, infection, contagion, hygiene, public health, and so on. Some interesting work on the memory of the Irish Famine has shown the possibilities of this kind of research into the memorialization of a community’s experience of ill-health or mass death and the ways in which collective understandings of the past inform the present. Histories of the Irish Famine have long been and remain heavily politicized, such that many historians remain sceptical of oral testimony, including the remarkable set of interviews with thousands of elderly people recalling the famine and

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its effects collected by the Irish Folklore Commission in the 1940s. However, this politicization is key to using such material to reveal broader truths. Rather than simply using such testimony as a means of uncovering the realities of the experience, there is considerable mileage in studying these narratives, stories, and memories as part of understanding the importance of the famine in Irish political and cultural identity during the past 150 years, and the role played by famine narratives in Anglo-Irish politics. The oral and folk memory of the famine can be read as part of a nationalist story of oppression at the hands of the English. Indeed, it can be argued that famine stories were instrumentalized by Republican voices in fostering Irish nationalism and revolutionary fervour, transforming the memory of the famine from a ‘commonplace’ story of rural blight, into a politicized tale of class oppression and colonial persecution.73 It is in addressing these kinds of debates around the historical memory of medical history that oral testimony could make a substantial contribution. This approach to the history of medicine is interested in what is forgotten in reminiscence as much as what is remembered. A number of historians have highlighted the absence of the Spanish Influenza of 1918 in British or North American memory culture despite the devastating impact it had on Western populations within living memory. As Crosby argues, the epidemic is rarely mentioned in oral histories, nor indeed in other forms of cultural memory: fiction, biography, literary culture, museums, or memorials.74 As Niall Johnson reveals, ‘in the local and national histories, in the national archives and in our collective memory, it has slipped away, leaving the merest of traces’; its impact was ‘masked by or conflated and merged into the larger story of the First World War’. Yet elsewhere it was not forgotten.75 James G. Ellis conducted oral histories in Tanzania in 1996 where he found the memory of the flu of 1918 embedded in traditions of storytelling. Moreover, he charted the ways in which following the epidemic various groups in Africa developed new rituals and customs to preserve and maintain good health. Ironically these newly developed customs, framed by the memory of influenza, subsequently shaped colonial and anthropological understandings of ‘traditional’ tribal custom and ethnic divisions. Anthropologists studied these customs as a means of delineating supposedly ancient ethnic or tribal groupings. A politics of memory approach to oral history testimony can reveal the ways in which the experience of illness and epidemics structured, framed, and organized social lives. Here oral history is used, not just to provide evidence of past experience, but as a means of serving an ongoing function that should also be subject to historical investigation. Such instances of forgetting and remembering demand to be studied by medical historians.

Conclusion Whereas in the 1990s oral historians lamented the lack of enthusiasm for their methodology among historians of medicine, some recent medical histories have been criticized for failing to adopt it.76 Oral history is now widely used in all areas of medical history. Yet,

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medical historians have remained relatively slow to incorporate some of the newer approaches to oral history into their practice. Too often medical historians seek to add human voices to the story of medicine, but oral history respondents, be they patients or clinicians, should not be viewed simply as repositories of information; instead, they need to be treated as retrospectively informed observers and participants embroiled in present and past debates. The ways in which informants choose to shape their stories and give meaning to the events and movements they were part of demands to be placed at the centre of the analysis.

Notes 1. Paul Thompson, ‘Oral History and the History of Medicine: A Review’, Social History of Medicine, 4 (2) (1991), 371–83. 2. Ibid. 376. 3. Raphael Samuel, ‘Local History and Oral History’, History Workshop Journal, 1 (1976), 191–208, 201; The Threepenny Doctor: Doctor Jelley of Hackney (London: Centerprise, 1983). For similar examples of investigations of the health environments of working-class communities, see Jocelyn Cornwell, Hard-Earned Lives: Accounts of Health and Illness from East London (London: Tavistock, 1984); Waltham Forest Oral History Group, ‘Touch Yer Collar, Never Swaller’: Memories of Childhood Illness before the Health Service (Walthamstow: The Workshop, 1984); Shirley Aucott, Mothercraft and Maternity: Leicester’s Maternity and Infant Welfare Services, 1900 to 1948 (Leicester: Leicestershire Museums, Arts and Records Service, 1997); Lucinda McCray Beier, For Their Own Good: The Transformation of English Working-Class Health Culture, 1880–1970 (Columbus: Ohio State University Press, 2008). 4. Nancy Tomes, ‘Oral History in the History of Medicine’, Journal of American History, 78 (2) (1991), 607–17. 5. http://www.history.qmul.ac.uk/research/modbiomed/wellcome_witnesses, accessed 6 May 2011. 6. Raymond Harris and Sara Harris,‘Therapeutic Uses of Oral History Techniques in Medicine’, International Journal of Aging and Human Development, 12 (1) (1981), 27–34; Joanna Bornat, ‘Oral History as a Social Movement: Reminiscence and Older People’, Oral History, 17 (2) (1989), 16–24; Philippe Denis and Nokhaya Makiwane, ‘Stories of Love, Pain and Courage: AIDS Orphans and Memory Boxes’, Oral History, 31 (2) (2003), 66–74; S. Field, ‘Beyond “Healing”: Trauma, Oral History and Regeneration’, Oral History, 34 (2006), 31–42. 7. Michael Nutkiewicz, ‘Diagnosis versus Dialogue: Oral Testimony and the Study of Pediatric Pain’, Oral History Review, 35 (1) (2008), 11–21. 8. S. Kakar, ‘Leprosy in Índia: The Intervention of Oral History’, Oral History, 23 (1) (1995), 37–45. 9. This point is made by Tomes, ‘Oral History in the History of Medicine’, 610. 10. Ibid. 608. 11. Kathryn Montgomery Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991); Nicky Leap and Billie Hunter, The Midwife’s Tale: An Oral History from Handywoman to Professional Midwife (London: Scarlet Press, 1993); Greg Wilkinson and Royal College of Psychiatrists, Talking about Psychiatry (London: Gaskell, 1993); J. Zalumas, Caring in Crisis: An Oral History of Critical

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12.

13. 14.

15. 16.

17. 18.

19. 20. 21. 22.

23. 24.

kate fisher Care Nursing (Philadelphia: University of Pennsylvania Press, 1995); S. Anderson, ‘ “I Remember It Well”: Oral History in the History of Pharmacy’, Social History of Medicine, 10 (2) (1997), 331–43; D. Russell, ‘An Oral History Project in Mental Health Nursing’, Journal of Advanced Nursing, 26 (1997), 489–95; G. Boschma, The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums, 1890–1920 (Amsterdam: Amsterdam University Press, 2003); David Clark, A Bit of Heaven for the Few?: An Oral History of the Hospice Movement in the United Kingdom (Lancaster: Observatory Publications, 2005); Duncan Mitchell and Anne-Marie Rafferty, ‘ “I Don’t Think They Ever Really Wanted to Know Anything About Us”: Oral History Interviews with Learning Disability Nurses’, Oral History, 33 (1) (2005), 77–87. M. Shkimba and K. Flynn, ‘ “In England We Did Nursing”: The Immigrant Experiences of Caribbean and British Nurses in Great Britain and Canada’, in Barbara E. Mortimer and Susan McGann (eds), New Directions in the History of Nursing: International Perspectives (London: Routledge, 2004), 141–57. Allen B. Weisse, Heart to Heart: The Twentieth Century Battle Against Cardiac Disease: An Oral History (New Brunswick, NJ, and London: Rutgers University Press, 2002). J. Drescher and J. P. Merlino, American Psychiatry and Homosexuality: An Oral History (London: Routledge, 2007); Chris Waters, ‘Book Review: Jack Drescher and Joseph P. Merlino, eds, (2007) American Psychiatry and Homosexuality: An Oral History’, History of Psychiatry, 20 (2) (2009), 252–4. Tomes, ‘Oral History in the History of Medicine’, 615. E. M. Tansey and L. A. Reynolds, Prenatal Corticosteroids for Reducing Morbidity and Mortality after Preterm Birth: The Transcript of a Witness Seminar Held by the Wellcome Trust Centre for the History of Medicine at University College London, London, on 15 June 2004 (London: Wellcome Trust Centre for the History of Medicine at UCL, 2005). R. Bayer and G. M. Oppenheimer, AIDS Doctors: Voices from the Epidemic: An Oral History (Oxford and New York: Oxford University Press, 2002). G. Smith and M. Nicolson, ‘Re-Expressing the Division of British Medicine under the NHS: The Importance of Locality in General Practitioners’ Oral Histories’, Social Science and Medicine, 64 (4) (2007), 938–48. S. Benison, ‘Oral History: Living Moments of Modern Medicine’, Bulletin of the New York Academy of Medicine, 36 (5) (1960), 344. B. Lindsay, ‘Review: Wellcome Witnesses to Twentieth Century Medicine: Volume 12, Maternal Care’, Social History of Medicine, 16 (1) (2003), 156–57. Roy Porter, ‘The Patient’s View: Doing Medical History from Below’, Theory and Society, 14 (2) (1985), 175–98. T. Atkins and R. Wilkinson, ‘A Personal Experience of Polio’, Oral History, 23 (1995), 82–4; J. K. Silver and D. J. Wilson, Polio Voices: An Oral History from the American Polio Epidemics and Worldwide Eradication Efforts (Westport: Praeger, 2007); Ann Shaw and Carole Reeves, The Children of Craig-Y-Nos: Life in a Welsh Tuberculosis Sanatorium, 1922– 1959 (London: Wellcome Trust Centre for the History of Medicine at UCL, 2009). Some interview projects have not been published, but collections of interviews have been archived. See, for example, the Papworth Oral History Project at http://www.cambridgeshire. gov.uk/leisure/archives/projects/papworth/papworth6.htm Department of Health, ‘Research Involving the NHS: Retention of Records’ (March 2007). Simon Guest, ‘Cure, Superstition, Infection and Reaction: Tuberculosis in Ireland, 1932–1957’, Oral History, 32 (2004), 63–72.

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25. Karen Hirsch, ‘Culture and Disability: The Role of Oral History’, Oral History Review, 22 (1) (1995), 1–27; Hunter, Doctors’ Stories. 26. Mary Jo Festle, ‘Qualifying the Quantifying: Assessing the Quality of Life of Lung Transplant Recipients’, Oral History Review, 29 (1) (2002), 59–86, at 84. 27. S. A. Leavitt, ‘A Private Little Revolution’, Bulletin of the History of Medicine, 80 (2006), 317–45. 28. Glenn Smith, Annie Bartlett, and Michael King, ‘Treatments of Homosexuality in Britain since the 1950s—an Oral History: The Experience of Patients’, British Medical Journal, 328 (7437) (2004), 427–9. 29. Cornwell, Hard-Earned Lives. 30. Beier, For Their Own Good; Maureen Sutton, We Didn’t Know Aught: A Study of Sexuality, Superstition and Death in Women’s Lives in Lincolnshire during the 1930s, ’40s and ’50s (Stamford: P. Watkins, 1992). 31. Ali Haggett, ‘Housewives, Neuroses and the Domestic Environment in Britain, 1945–70’, in Mark Jackson (ed.), Health and the Modern Home (London: Routledge, 2007), 84–108. 32. Guest, ‘Cure, Superstition, Infection and Reaction’. 33. R. M. Packard, ‘Post-Colonial Medicine’, in Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2000), 97–112. 34. Julie Livingston, ‘Pregnant Children and Half-Dead Adults: Modern Living and the Quickening Life Cycle in Botswana’, Bulletin of the History of Medicine, 77 (1) (2003), 133–62. 35. Arthur McIvor and Ronald Johnston, Miners’ Lung: A History of Dust Disease in British Coal Mining (Aldershot, UK, and Burlington, VT: Ashgate, 2007), 238. 36. Ibid. 37. Wendy Rickard, ‘HIV and AIDS Testimonies in the 1990s’, in Joanna Bornat et al. (eds), Oral History, Health and Welfare (London/New York: Routledge, 2000), 227–48. 38. Smith, Bartlett, and King, ‘Treatments of Homosexuality in Britain since the 1950s’. 39. Some historians have profitably scoured asylum records for patients’ views. A. Beveridge, ‘Voices of the Mad: Patients’ Letters from the Royal Edinburgh Asylum, 1873–1908’, Psychological Medicine, 27 (4) (1997), 899–908; A. Beveridge, ‘Life in the Asylum: Patients’ Letters from Morningside, 1873–1908’, History of Psychiatry, 9 (36) (1998), 431–69; David Wright, Mental Disability in Victorian England: The Earlswood Asylum, 1847–1901 (Oxford: Oxford University Press, 2001); Joseph Melling and Bill Forsythe, The Politics of Madness: The State, Insanity and Society in England, 1845–1914 (London and New York: Routledge, 2006); Akihito Suzuki, Madness at Home: The Psychiatrist, the Patient, and the Family in England, 1820–1860 (Berkeley: University of California Press, 2006); L. Wannell, ‘Patients’ Relatives and Psychiatric Doctors: Letter Writing in the York Retreat, 1875–1910’, Social History of Medicine, 20 (2) (2007), 297–313; Roy Porter, A Social History of Madness: Stories of the Insane (London: Weidenfeld and Nicolson, 1987). 40. On the methodological challenges posed by asylum records, see Michael MacDonald, ‘Madness, Suicide and the Computer’, in Roy Porter and Andrew Wear (eds), Problems and Methods in the History of Medicine (London and New York: Croom Helm, 1987), 207–29. 41. Rebecca Fido and Maggie Potts, ‘ “It’s Not True What Was Written Down!” Experiences of Life in a Mental Handicap Institution’, Oral History, 17 (2) (1989), 31–4. 42. Ibid. 34. 43. Diana Gittins, Madness in Its Place: Narratives of Severalls Hospital, 1913–1997 (London: Routledge, 1998).

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44. G. Reaume, ‘ “Keep Your Labels off My Mind! Or Now I Am Going to Pretend I Am Crazy But Don’t Be a Bit Alarmed”: Psychiatric History from the Patients’ Perspectives’, Canadian Bulletin of Medical History, 11 (1) (1994), 397–424. 45. Packard, ‘Post-Colonial Medicine’, 97. 46. On the complex rhetorics that constitute disease narratives, see David Harley, ‘Rhetoric and the Social Construction of Sickness and Healing’, Social History of Medicine, 12 (3) (1999), 407–35. 47. Kerry Davies, ‘ “Silent and Censured Travellers”?: Patients’ Narratives and Patients’ Voices: Perspectives on the History of Mental Illness since 1948’, Social History of Medicine, 14 (2) (2001), 267–92. 48. D. Pollock, Telling Bodies Performing Birth: Everyday Narratives of Childbirth (New York: Columbia University Press, 1999); P. E. Klassen, Blessed Events: Religion and Home Birth in America (Princeton, NJ: Princeton University Press, 2001). 49. William Ray Arney and Jane Neill ‘The Location of Pain in Childbirth: Natural Childbirth and the Transformation of Obstetrics’, Sociology of Health and Illness, 4 (1) (1982), 1–24; C. Carpenter, ‘Tales Women Tell: The Function of Birth Experience Narratives’, Canadian Folklore Canadien 7 (1985), 21–34; C. G. Borst, Catching Babies: The Professionalization of Childbirth, 1870–1920 (Cambridge, MA: Harvard University Press, 1995); M. Akrich and B. Pasveer, ‘Embodiment and Disembodiment in Childbirth Narratives’, Body and Society, 10 (2004), 63–84. 50. Tess Cosslett, Women Writing Childbirth: Modern Discourses of Motherhood (Manchester: Manchester University Press, 1994). 51. Angela Davis, ‘Oral History and the Creation of Collective Memories: Women’s Experiences of Motherhood in Oxfordshire c. 1945–1970’, University of Sussex Journal of Contemporary History, 10 (2006), 1–10; Leap and Hunter, Midwife’s Tale. 52. P. Ramcharan and J. R. Cutcliffe, ‘Judging the Ethics of Qualitative Research: Considering the “Ethics as Process” Model’, Health and Social Care in the Community, 9 (6) (2001), 358–66; J. Katz, ‘Ethical Escape Routes for Underground Ethnographers’, American Ethnologist, 33 (4) (2006), 499–506. 53. Z. M. Schrag, ‘How Talking Became Human Subjects Research: The Federal Regulation of the Social Sciences, 1965–1991’, Journal of Policy History, 21 (1) (2009), 3–37. 54. Mark Israel and Ian Hay, Research Ethics for Social Scientists: Between Ethical Conduct and Regulatory Compliance (Thousand Oaks, CA: Sage, 2006), 1; Rickard, ‘HIV and AIDS Testimonies in the 1990s’, 58–9. 55. Ramcharan and Cutcliffe, ‘Judging the Ethics of Qualitative Research’. 56. L. Shopes,‘Institutional Review Boards Have a Chilling Effect on Oral History’, Perspectives: American Historical Association Newsletter (2000), at http://www.theaha.org/perspectives/ issues/2000/0009/0009vie1.cfm 57. Robert Townsend and Meriam Belli, ‘Oral History and IRBs: Caution Urged as Rule Interpretations Vary Widely’, Perspectives, 42 (9) (December 2004), at http://www. historians.org/perspectives/issues/2004/0412/0412new4.cfm; Robert Townsend, with Carl Ashley, Mériam Belli, Richard E. Bond, and Elizabeth Fairhead, ‘Oral History and Review Boards: Little Gain and More Pain’, Perspectives, 44 (2) (February 2006), at http://www. historians.org/perspectives/issues/2006/0602/0602new1.cfm 58. R. Harris and E. Dyson, ‘Recruitment of Frail Older People to Research: Lessons Learnt through Experience’, Journal of Advanced Nursing, 36 (5) (2001), 643–51.

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59. Meryl S. Brod and Richard I. Feinbloom, ‘Feasibility and Efficacy of Verbal Consents’, Research on Aging, 12 (3) (1990), 364–72; D. M. High and M. M. Doole, ‘Ethical and Legal Issues in Conducting Research Involving Elderly Subjects’, Behavioral Sciences and the Law, 13 (3) (1995), 319–35. 60. Roberta S. Gould, ‘None of Anybody’s Goddamn Business?: Oral History and the Communist Past’, Institutional Review Blog, posted 29 September 2007. 61. Matt Bradley, ‘Silenced for Their Own Protection: How the IRB Marginalizes Those It Feigns to Protect’ (2008), available at http://www.acme-journal.org/vol6/MB.pdf 62. Paul Weindling, ‘ “Jeder Mensch hat einen Name”: Psychiatric Victims of Human Experimentation under National Socialism’, Die Psychiatrie (forthcoming). 63. Geoffrey Raume, ‘Portraits of People with Mental Disorders in English Canadian History’, 31 Canadian Bulletin of Medical History, 17 (1&2) (2000), 93–125. 64. Franca Iacovetta and Wendy Mitchinson, ‘Introduction: Social History and Case Files Research’, in On the Case: Explorations in Social History (Toronto: University of Toronto Press, 1998), 6. 65. Nancy Janovicek, ‘Oral History and Ethical Practice: Towards Effective Policies and Procedures’, Journal of Academic Ethics, 4 (1) (2006), 157–74. 66. J. Bornat, ‘A Second Take: Revisiting Interviews with a Different Purpose’, Oral History, 31 (2003), 47–53. 67. E. Taylor Atkins, ‘Forum on IRBs: Oral History and IRBs: An Update from the 2006 HRPP Conference’, Perspectives, March 2007, available at http://historians.org/Perspectives/ issues/2007/0703/0703vie2.cfm 68. As well as oral histories, museums are an equally rich source of information to be analysed here. We might explore, for example, why so many medical museums have focused on displays of ‘blood, guts and jars of preserved body parts’ and frightening symbols of past medical practices, such as gruesome surgical tools. We might ask what these exhibits and their implicit contrasts between past and present tell us about curators’ and audiences’ understandings of the history of medicine and the significance of such stories for modern society. See, for example, K. Arnold, ‘Time Heals: Making History in Medical Museums’, in Gaynor Kavanagh (ed.), Making Histories in Museums (London/New York: Continuum, 2005), 15–29. For an example of what this sort of history can do on a non-medical topic, see Lucy Noakes, ‘Making Histories: Experiencing the Blitz in London’s Museums in the 1990s’, in Gordon Martel (ed.), The World War Two Reader (New York: Routledge, 2004), 422–34. 69. Helen Busby and Paul Martin, ‘Biobanks, National Identity and Imagined Communities: The Case of UK Biobank’, Science as Culture, 15 (3) (2006), 237–51; Jacqueline Scott and Lilian Zac,‘Collective Memories in Britain and the United States’, Public Opinion Quarterly, 57 (3) (1993), 315–31, at 319. 70. R. Eyerman, Cultural Trauma: Slavery and the Formation of African American Identity (Cambridge: Cambridge University Press, 2001). 71. Heather Carmack, Benjamin Bates, and Lynn Harter, ‘Narrative Constructions of Health Care Issues and Policies: The Case of President Clinton’s Apology-by-Proxy for the Tuskegee Syphilis Experiment’, Journal of Medical Humanities, 29 (2) (2008), 89–109; S. M. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: University of North Carolina Press, 2009). 72. L. Diack, ‘Myths of a Beleaguered City: Aberdeen and the Typhoid Outbreak of 1964 Explored through Oral History’, Oral History, 29 (2001), 62–72.

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73. Roy Foster, The Irish Story: Telling Tales and Making It Up in Ireland (London and New York: Allen Lane Penguin, 2001), Cormac Ó Gráda, ‘Famine, Trauma and Memory’, Béaloideas, 69 (2001), 121–43. 74. A. W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918 (Cambridge: Cambridge University Press, 2003); Niall Johnson, Britain and the 1918–19 Influenza Pandemic: A Dark Epilogue (London: Routledge, 2006). 75. Johnson, Britain and the 1918–19 Influenza Pandemic, 163, 179. 76. Michelle Winslow and Graham Smith, ‘Medical Ethics and Oral History’, in Donald A. Ritchie (ed.), Oxford Handbook of Oral History (Oxford: Oxford University Press, 2010), 372–92.

Select Bibliography Bayer, R., and G. M. Oppenheimer, AIDS Doctors: Voices from the Epidemic: An Oral History (Oxford and New York: Oxford University Press, 2002). Beier, Lucinda McCray, For Their Own Good: The Transformation of English Working-Class Health Culture, 1880–1970 (Columbus: Ohio State University Press, 2008). Davies, Kerry, ‘ “Silent and Censured Travellers”?: Patients’ Narratives and Patients’ Voices: Perspectives on the History of Mental Illness since 1948’, Social History of Medicine, 14 (2) (2001), 267–92. Hunter, Kathryn Montgomery, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991). McIvor, Arthur, and Ronald Johnston, Miners’ Lung: A History of Dust Disease in British Coal Mining (Aldershot and Burlington, VT: Ashgate, 2007). Ritchie, Donald A., Oxford Handbook of Oral History (Oxford: Oxford University Press, 2010). Thompson, Paul, ‘Oral History and the History of Medicine: A Review’, Social History of Medicine, 4 (2) (1991), 371–83. Tomes, Nancy, ‘Oral History in the History of Medicine’, Journal of American History, 78 (2) (1991), 607–17.

chapter 34

m edic a l fil m a n d telev ision: a n a lter nativ e path to the cu lt u r e s of biom edici n e t imothy b oon

If modern medicine was a child of the dawn of the long nineteenth century, then the moving image must be considered a grandchild, born at its dusk. In the twentieth century, medicine developed at the same time that film, and then television, came of age. In the genres most closely allied with medicine, the different modes of film and television differentially favoured various aspects of biomedicine across the period; sometimes this was because of a ‘push’ from medicine, seeking influence with the general audience, and sometimes it was a ‘pull’ from film and television producers seeking to convey a specific point of view or discuss a particular issue. It is clear that these eruptions of medicine into the public sphere have much to tell us about the cultural place of twentieth-century biomedicine. Accordingly, this chapter is concerned with the triangular territory between biomedicine, relevant moving image media production, and lay people—sometimes cinematic subjects, sometimes patients, and sometimes audiences. The examples quoted—mainly British—arise from the period stretching from the late nineteenth century up to the 1960s. The significant costs and effort involved in producing medical films and programmes make their existence in certain times and places particularly interesting evidence for the terrain of biomedicine in the past. Understanding how they came to be made and used gives access to the politics and social attitudes of participants in interesting ways. This chapter follows the established tripartite division of modern medicine into medical laboratory science, public health, and clinical medicine, exploring in turn the use of the cine camera as an instrument in the medical laboratory sciences, health education films and documentaries about the public health, and television programmes concerned with medicine in the first two post-war decades. Not only did the different aspects of

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medicine produce different modes of film, but—at the level of coarse generalization— the laboratory medicine, public health, and clinical modes of moving image culture emerged separately and in that sequence, each developing semi-independently and in some quantity from the 1890s, 1910s, and 1950s, respectively. So, in the three main sections that follow, the coverage of each mode of film-making is concentrated in the decade of its emergence. Medicine provides a fertile territory for studying relationships between lay publics and élite discourses in science and technology more broadly, in which all media of communication have had a role as the ‘vehicles of communication’ between science and the public. Within this area, visual culture has long been a bit part player in the history of medicine. A few examples of research on still images are indicative of a growing field. Fox and Lawrence’s Photographing Medicine proposes a classification of medical photographs and includes a valuable introductory essay on the issues of studying and using such images. Ludmilla Jordanova’s review of this work for Social History of Medicine goes beyond this work to pose thought-provoking questions valuable for the whole area. Roy Porter in his Bodies Politic looked at the visual aspects—caricature, illustrations, and sketches—of medicine in the long eighteenth century and, more recently, Roger Cooter and Claudia Stein have undertaken an extensive study of health posters.1 Another current has been the study of ‘medicine and the media’, exemplified by Anne Karpf ’s Doctoring the Media, her valuable study of the British territory published in 1988.2 Karpf, a journalist herself, concentrates on medical reportage. Th e risk of a focus on media may be a tendency to see medicine as something reported and as distinct from the media—newspaper, magazine, radio, newsreel, television—that carry any reports. Naomi Rogers and Susan Lederer’s useful contribution to Cooter and Pickstone’s Medicine in the Twentieth Century, with its focus also on media, exemplifies one of the difficulties of this territory, that of definition.3 The term ‘media’ here denotes a field that extends beyond reportage into many areas of the representation of biomedicine: novels, films, television, radio, oil paintings. The very diversity of the media treated indicates how underdeveloped this area of study is. In putting together different forms of representation that individually have had varying relationships to different areas of medicine at different times, the scope for reliable generalization is significantly curtailed. My approach here instead defines its field by emphasizing the relationships within medical film- and television-making between doctors and administrators, on the one hand, and film and television directors and producers, on the other. The moving image culture of medicine is rather underexplored. As a rule, mainstream fictional feature films and—to a lesser extent—television programmes with medical themes have received greater coverage than the main concerns of this chapter, the films that were the instruments of medicine (the products of laboratory work or health education films), or which represented medicine and public health in various documentary genres.4 Most of the dozen essays in the wide-ranging 2005 collection Signs of Life: Medicine and Cinema use medical films or genres as lenses to explore issues, including the state of the health services, ethics, and disability.5 Medicine’s Moving Pictures: Medicine, Health, and Bodies in American Film and Television from

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2007 is a diverse collection with many excellent contributions which, all the same, demonstrate that those who write about medical films and television are not yet a community with shared approaches and concerns.6 Brian Glasser’s Medicinema is a series of thoughtful essays on the ways that feature films have represented doctors and medical practice.7 Issues of gender and social power have made representations of nurses an enduring theme in medical historical studies of feature films.8 Kirsten Ostherr’s Cinematic Prophylaxis is a parallel account of Cold War era science-fiction films and World Health Organization discourse on contagion.9 Joseph Turow’s Playing Doctor details the development of series such as the Dr Kildare franchise, and later television soap operas, including ER, Grey’s Anatomy, House, and Scrubs.10 But, for ‘factual’ films, the best first recourse is often to refer to more general reference books, such as Rachael Low’s two surveys of the 1930s.11 Several scholars ‘moonlighting’ at the edge of their own more pressing concerns have produced valuable contextual studies. These include Christopher Lawrence’s paper on the William Harvey tercentenary film, Geoffrey Crothall’s analysis of British slum clearance films, and David Cantor’s work on the use of films in cancer education.12 Of the more substantial works, Martin Pernick’s The Black Stork (1996) is an exemplary study of a single film and the context of its production.13 Ulf Schmidt’s Medical Films, Ethics and Euthanasia in Nazi Germany is a searing account of the use of particular films in interwar Germany.14 My own Films of Fact brings centre stage the genres of factual films and television defined in their time as scientific, and aims to producing an extended account encompassing many films and programmes produced over sixty years.15 It is generally still the case, however, that studies of the medical moving image concentrate on the supply side; they talk of the circumstances of production and the motivations of producers. The impact on lay people, whether as audiences or patients, has most often been elided. The work, however good, embodies a paradox: that analysts of genres that were, with one exception, primarily intended to have an impact on large lay audiences, seem unwilling or unable to engage with the impact that these had on lay people in the past.

Use of the cine camera as an instrument in medical science The medical transformations of the long nineteenth century, incorporating revolutions in diagnosis and medical science, resting on the introduction of new technologies and techniques, are familiar to medical historians. Visualization, ‘the translation of physiological actions into the languages of machines’, was a foundational element of contemporary medical understanding. Most histories now also ascribe the origins of cinematography in part to this same visualizing culture, notably to the chronophotographic studies of the French physiologist Étienne-Jules Marey (1830–1904).16

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After the Lumière Brothers first demonstrated the technology of projected films in 1895, doctors very soon began to experiment, applying it as an instrument for scientific research, just as they did with clockwork, medical electricity, X-rays, and radium. It is typical of the fluid world of late-nineteenth-century technomedicine that we find a diversity of practitioners choosing to experiment with this new technology and in a wide range of places. In Vienna, Ludwig Braun filmed the contractions of a dog’s heart in 1898, in Berlin Paul Schuster produced studies of patients with conditions including Parkinson’s disease, and New York doctor Robert Watkins made micro-cinematographic renderings of blood corpuscles, as Marey had before him. The Edinburgh consultant ear, nose, and throat surgeon John Macintyre created a stop-motion X-ray film of a frog’s legs flexing and the French surgeon Dr Eugène-Louis Doyen started making surgical films to demonstrate technique. For doctors and medical scientists, to employ the cinematograph was to continue within the culture of visualization that had contributed to its invention in the first place.17 Hannah Landecker has suggested that cinematography had a revolutionary potential in the sciences, especially as it made visible phenomena that were too slow or too fast to be perceptible.18 The advocates of scientific cinematographic experimentation frequently asserted this potential across the twentieth century. However, despite many interesting experiments using cinematography, in the absence of many detailed studies, the case for the cine camera as a historically significant instrument of medical science is difficult to make. Clinical researchers also used the cine camera, for example in neurology, where comparable use was made in Britain and the United States of the cine camera to record and analyse the physical symptoms of shell shock, epilepsy, and related conditions.19 There has been no synthetic or systematic study of this aspect of medical film-making. In this whole class of experimental medical films, the experimenters were generally also the camera operators; there was no extra-medical mediation. None of these films, made by doctors for the medical lecture theatre or the scientific meeting, was primarily intended to be seen by the general public. There were interesting exceptions. For example, Doyen’s film of the surgical separation of Siamese twins was copied and sold to a fairground freak show exhibitor.20 Macintyre’s frog leg film was also shown to a Ladies’ Night at the Glasgow Philosophical Society.21 But these are exceptions: these short experimental films were certainly products of the visualizing armoury of the medical sciences, but they were not part of its public culture.

Public health Public health, by contrast, is an aspect of biomedicine that explicitly addresses the public; in health education, films were the instruments of public health and, accordingly, significant numbers were made. These films have acted to promote particular views of the public health in parallel to their ostensible work of seeking to persuade the general

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public to change their health behaviour. There has been a similar contestation where public health themes have been represented in documentary reportage. Health education film-making is therefore rather different from the first genre, in terms of both the groups that made the films and those that saw them. Government—in the shape of the Ministry of Health (MoH), formed in 1919—and the majority of doctors agreed on the importance of health education. It became one of the key preventive medical technologies of the interwar period, as George Newman, Chief Medical Officer, wrote in 1925: In every direction the prevention of disease is becoming a personal concern . . . Public provision . . . cannot make particular men, women or children feel well day by day. It is neglect of this personal aspect which is now restricting the operations and results of Preventive Medicine in many fields; and it is this personal aspect which accentuates the need for a greater degree of public education.22

But it did not follow that this public education should be the direct business of the state, in this age of mixed public–private health polity. In 1920, following internal discussions at the Ministry, and under the shadow of the Geddes financial ‘axe’, officials confirmed that practical health education should not normally be undertaken centrally, but should instead be delegated to Medical Officers of Health (MOH) at the periphery in the towns, cities, and rural districts and to voluntary health associations. Here, Ministry officials had developed a fundamentally hierarchical model of communication, with educated intermediaries sitting between the state and the public. As Newman put it, ‘governmental action is the outcome of public opinion, and this in turn is formed by the more educated section of the people and by individual exponents.’23 A small number of interwar health education films was made by Medical Officers in the local authorities, even though the Ministry did not provide funds for film-making.24 The Medical Officers, who were the main players in health education in the public sector, could usually not afford to make films and, if they did, it was on an amateur basis; so here again doctors doubled as film-makers. Exceptionally, Bermondsey Borough Council made about eighteen films as part of their experiment in municipal socialism, often using special projector vans to show efforts such as Where There’s Life, There’s Soap in the borough’s streets.25 This film featured the verse, designed for children to chant, ‘I’d wash if I’d been born a fish | Or e’en a humble frog. | Alas! Alas! my habits are, | the habits of a hog’. A cluster of local authority films that demonstrates how films acted as advocacy for particular viewpoints is the five or so made by Medical Officers to promote diphtheria immunization, at that stage permitted but not promoted by the MoH. The Empty Bed, a silent film made in Camberwell in 1934–5, is a surviving example.26 Here the public health doctors, W.W. King-Brown, former MOH of Bermondsey, and Guy Bousfield, long-term advocate—and practitioner in three London boroughs—of diphtheria immunization, doubled as film-makers. Very few Medical Officers made health films, but most showed those made by other agencies, notably the voluntary health associations, which were responsible for the largest number. These were private sector organizations devoted to improving the public

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health in various ways; for some it was particular diseases, such as venereal disease or tuberculosis, while others, including The People’s League of Health led by the actress Olga Nethersole, worried about the moral state of the population, their uptake of medical services, their cleanliness, or, in the case of the Eugenics Society, their genetic decline. These organizations were quasi-political, providing a platform for women (without the vote before 1928) to become leaders, for aristocrats seeking to retain a role in a period of decline, and for aspirant middle-class professionals, including doctors, to assert a particular view of what mattered within medicine. Most active participants in these associations were committed to private sector delivery of health education; for them health propaganda was not the state’s business. Thirty-eight of these voluntary associations had as many as 180 films in distribution in the interwar period. The British Social Hygiene Council (BSHC), the only organization consistently receiving substantial central or local government funding, generated, or handled British distribution of, forty-five films between 1919 and 1939. Their films generally used the ‘moral tale’ approach, fictional stories using moral narratives (often featuring sequences of innocence, temptation, transgression, punishment, and atonement) intended to convey a health implication. To take one typical example, A Test for Love (1937) is the story of Betty, who, thinking her fiancé Jim has deserted her for another woman, allows herself to be led astray by George, an unsuitable young man who takes her out, plies her with drink, then in a series of symbolic acts, drives off the road, and seduces her in his expensive American car. The result is that Betty is infected with gonorrhoea, a fact discreetly and briefly signposted in the doctor’s note she shows to the clinic. Following an unsuccessful attempt to gain treatment while staying with a prudish aunt, she turns to Mrs. Thompson, a member of the local authority’s Public Health committee, who advises her of the services provided by the venereal disease clinic at the public expense. Betty attends the clinic and, after an unspecified period, returns to everyday life; she believes that she will be obliged to live the life of a spinster. Jim discovers her and is insistent they should get married.27 It is possible to reconstruct certain audience aspects of films of this kind. Cinemagoing was a highly significant aspect of 1930s British social life, as Jeffrey Richards has shown, and health educators hankered after a share of that audience. The Health Education Yearbook stated in 1939 that ‘the value of the Film as an impressive visual medium of education needs no emphasis’, betraying a commonly held faith that the power of celluloid could be put to use for health propaganda purposes. Allen Daley, Medical Officer for Blackburn, commented that ‘practically everywhere audiences of . . . 3,000 can be obtained . . . where cinema films are shown’. The fact that as many as 350 health education films were made and distributed in this period, despite the fact that even the cheapest were normally beyond the reach of the individual local health authorities, confirms the high faith that participants invested in their power.28 However, health education films up to the time of the Second World War present a puzzle to the modern mind because the people involved in their production simply assumed that film was a powerful medium for health propaganda.29 They judged the success of films in terms of audience numbers, not by any surveillance via opinion surveys, or of consequent

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attendance at clinics, or any of the techniques that are now the common sense of current public health practice. These measures came later. Health education films are the most numerous and typical of broadly medical films from the interwar period; their existence expresses something essential about medicine’s relationship to the public at the time. The Ministry continued to maintain the ‘arm’s length’ model of health education provision for the first eighteen months of the Second World War by delegating production to the voluntary health associations’ umbrella organization, the Central Council for Health Education. Thereafter production of such films was taken under the wing of the Ministry of Information, an arrangement in which the MoH had significant influence over the style and content of campaigns. Many of the films, including for example A Subject for Discussion (1943) on venereal disease, abandoned the ‘moral tale approach’. The post-war history of health education films has so far received very little scholarly attention, so generalization is difficult. However, in the period after 1945, there was a substantial reversion to the ‘arm’s length’ health education polity, with much responsibility falling to the renamed Health Education Council and individual organizations. Where health issues were considered to be of national importance, some educational films continued to be made directly under the auspices of the state—such as J. B. Holmes’s The People at No.19 (1949), which used a dramatic approach to press a message about women carrying undiagnosed venereal infections acquired during the social turmoil of war. If, however, the public health polity of the interwar period created the ‘ecological niche’ that favoured the production of health education films as discussed, other features of the period’s culture and economy equally gave rise to other genres. Medical scientists were producing new understandings, notably in nutrition science, that provided alternatives to the personal hygiene ideology of most health education. Whereas in the 1920s the MoH’s careful response to the slow expansion of the state was delegation to the periphery of public communication, other departments of state took a more active role. Both the Empire Marketing Board (EMB) and Post Office (GPO) invested in expansive public relations campaigns featuring posters, films, and other media.30 This tendency was already well established when the Depression hit in the 1930s and it was the application of skills learnt in the government film units to social problems exacerbated by the Depression that created the new cinematic genre of the public health documentary. The first films were financed by industrial organizations, in an early example of sponsored film-making. From the mid-1930s, the gas industry pioneered a subtle commercial use of documentary films in their public relations strategy. Responding to the way that the electricity industry, their main competitor for domestic fuel supply, was promoting itself as an avatar of modernity, gas fought back, representing itself as a socially conscious modern industry, using films such as Housing Problems (1935) and Enough to Eat? (1936).31 It is arguable that these films established a genre that has had great longevity in moving-image culture, via prestige films on nutrition, including World of Plenty (1943), television reportage, such as Special Enquiry (1952–7), and television documentary, including Horizon (from 1964).32

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Medical television in the first two post-war decades The Second World War period transformed the organization of medical services, while the establishment of the National Health Service (NHS) from 1948 coincided with the beginning of an acceleration in the development of new diagnostic, therapeutic, and care technologies. The relative prosperity of the 1950s and subsequent decades helped to improve life expectancy and conducted the British population through an epidemiological transition in which infectious diseases were gradually replaced by degenerative conditions as the major causes of death. This prosperity also converted television from its pre-war beginnings as a luxury service for a very few licence-holders around the capital to a service serving a nation of television viewers. By 1955 4,500,000 homes in the United Kingdom had television sets and there were nearly four times as many by 1964 when BBC2 started. A side-effect was the creation of a new line of communication about clinical medicine, independent of medical mediation, to the lay public. These were not the first non-fiction clinical medical films; there had been hospital fund-raising films, such as An Ancient House of Healing (1937), in the interwar period and sporadic films on clinical topics during the war, including Plastic Surgery in Wartime (1941), but these were rare enough to make them exceptions. If the scope of this chapter were expanded to include technical and training films aimed at medical audiences, then many more titles could be included, for example, the Technique of Anaesthesia series (Realist Film Unit, 1944–5), but vanishingly little historical work has been done on these.33 Science and medicine had, in their different ways, both been well established on radio before the Second World War.34 When television began broadcasting again after a wartime interval from 1946, it continued to maintain its ‘younger sibling’ status in relation to radio for several years. It was only when it gained, in October 1950, full departmental status, a Controller, and its own seat on the Board of Management that it began to overcome this lowly status.35 To outsiders, the Fifties was the decade in which television began to seem the natural medium to represent many subjects, on account of the audience that could be reached. But it is clear that in television it was primarily the broadcast institutions and individual broadcasters that determined how medicine and health were represented, and only secondarily doctors. This was because of the BBC’s sober ethos that included medicine within the serious subjects that were considered worthy of coverage. These subjects otherwise included politics, religion, the arts, and current affairs, for example. Those in charge of television non-fiction in the 1950s inhabited a crucible of expansion, serving the increase of viewers and seeking to develop new and compelling genres of broadcasting that responded to the particular characteristics of the medium. In particular they focused on the fact that virtually everything broadcast was live; so they made a fetish of the simultaneity of the medium. In terms of coverage of clinical medicine and

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public health, this was seen early in the Fifties in the form of documentary dramas, performed live in the studios at Alexandra Palace, with some pre-filmed inserts to cover exteriors. These plays included To Save a Life (1951), Dangerous Drugs (1952), Family Doctor (1952), Under Her Skilled Hand (on the teaching hospitals and nursing, 1953), Outbreak (about foot and mouth disease, 1953), Behind These Doors: Doctor’s Waiting Room (1954), and Medical Officer of Health (dramatizing a smallpox outbreak, 1954). The use of the documentary drama approach, showing medical practice within the structure of narrative plots, had the tendency of rendering the coverage of medicine as a social phenomenon, rather than as a scientific one. Medical science was more likely to be picked up as items in the various sporadic live, studio-based, science news magazine programmes, including Science is News and Frontiers of Science. Longer, more highly constructed, documentary films made complete before broadcast were very occasional features of the schedules. These included, in the United Nations-supported strand, The World is Ours in 1954–5, World Nurse (on World Health Organization nursing services), World Population, and The Invisible Enemy (on the World Health Organization’s virology programme). Britain’s medical services were all also the subject of a substantial broadcast film documentary, On Call to a Nation (1958). Written and produced by Richard Cawston, this was a seventy-five-minute examination of the state of the NHS ten years after its foundation.36 However, the series that dramatically changed the representation of medicine on television was the original series of Your Life in Their Hands (YLITH), broadcast in the spring of 1958. This is a key example of how the interaction between institutional structure—in this case at the BBC—and representational form produced specific outcomes in terms of the public culture of medicine. The documentary dramas mentioned above had all been made in the BBC’s Documentary Department, which had been closed in 1955. Most broadly scientific output came from the ‘Television Talks’ department, which specialized in studio-based magazine and news programmes. However, a new BBC internal competitor arrived in the mid-Fifties once the Outside Broadcast (OB) Department began to make programmes, rather than just providing a service to other departments. Producers were encouraged to develop new types of OB programmes, partially because the quantity of OB equipment in the regions had been increased so that they could better cover sports matches. As these mainly took place at weekends, equipment was under-used on weekdays. The Department began to concentrate on ‘built OB’ programmes, as participants described them: OB that did not merely transmit existing events—such as the Coronation—into people’s homes, but used real venues as television studios for programmes that reported activities authentic to the chosen site. The OB producers Aubrey Singer and Bill Duncalf became crucial players in the development of science and medical television within the department. The breakthrough science OB series were Eye on Research, produced by Singer, which took live outside broadcast cameras to the laboratory bench, and YLITH, produced by Duncalf, which went into hospitals. YLITH marked a significant moment in the relationship between programme-makers and the medical establishment. Kelly Loughlin has analysed the response in Parliament

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and how the Royal College of Surgeons and especially the British Medical Association (BMA) reacted negatively to the series.37 In an editorial about ‘disease education’ by the BBC, the British Medical Journal asserted that: The treatment of disease is first and foremost a highly individual matter between the doctor and the patient . . . the hospitals are now owned by the State, and therefore the . . . Ministry of Health can give a national broadcasting organization permission to enter the public wards [but this] does not justify the intervention of the television camera in the doctor-patient relationship.38

One doctor’s letter to the British Medical Journal complained that a patient had worked out from the programme on cancer that he was suffering from the condition, a fact that the doctor had been hiding from him. The BMA’s choice of the term ‘disease education’ places the opening-up of clinical medicine to televisual representation in a contrast with health education, which was seen as an acceptable subject for the medium. The author was complaining in sum that the clinical encounter should remain private and, in blaming the MoH, was continuing in the vein that had seen the medical profession campaigning against the NHS a decade earlier. These were arguments about the erosion of medical authority. As Loughlin shows, these responses coincided with the high-water mark of a BMA model of media relations centred on Fleet Street and medical politics, which may be seen as the BMA’s trades union side. Within a couple of years, the Association had moved towards a form of public relations centred on promoting the scientific side of medicine, and was much more friendly towards television, partially, I suggest, as a result of YLITH. The inclusion of real patients in programmes was not quite unheard of, but it was still unusual and their presence on live television was certainly new. Norman Swallow, a senior television producer, expressed the excitement of live television: ‘the viewer is watching something which is truly taking place at the very moment of transmission, and no one really knows what will happen’. He went on more specifically to comment on cameras watching ‘surgeons at work, performing a real operation on a real patient’. His view was that ‘to transmit such a sequence live is infinitely more effective than to pre-record it, for there is always an added sense of occasion in being present when something dramatic is actually happening. To be allowed to watch something which took place yesterday or last week is a poor substitute.’39 In three of the ten programmes in this first series, the viewers saw operations in progress. Although the programmes went out live, these sequences were filmed in advance and run into the programmes at the appropriate point. Three aspects of relations with lay people are of interest here: the recruitment of patients to appear, their actual performances, and reception by the general audience. The BBC Archive file for the ninth programme in the first YLITH series, Machinery for Living from Leeds General Infirmary (LGI), for example, though fairly extensive, is mainly silent on the recruitment of patients to the programme. There were ethics in play, but they were literally at the level of life and death: the programme was intended to include sequences of dialysis and open-heart surgery. However, two of the patients

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whose operations were filmed in March 1958 for this programme died within the week, and it was decided that it would be improper to use the footage. Both the LGI and the BBC wanted to include footage of operations; it was a technicality and not patient issues that prevented this from happening. A consultant stated that he had patients on the ward awaiting surgery who would have been made available for filming, but the technician operating the Melrose Heart Lung Machine became unavailable because of pneumonia and it proved impossible to film the machine for an actual operation; what you see is a mock-up.40 The interviewed patients come across as highly deferential; the surgeons are articulate and do most of the talking; the patients nervously, respectfully, and briefly answer direct questions. You might say that these patients appear as anxious about the new technology of television as of high-tech medicine. The doctors and surgeons, by contrast, seem confident and at home with both. In all this, the patients are very much the objects of experimental surgical technique, as they had been since the Paris medicine of 150 years earlier.41 In the case of this series, it is possible to learn a substantial amount about the audience response, because not only was each of the programmes studied by the audience research department, but the BBC also undertook an extended analysis on the grounds that ‘the series provoked much public comment, in the medical and lay press and elsewhere, by no means all of it favourable’. A selected group of viewers was asked to provide data to answer questions such as ‘Did the series cause more (or fewer) viewers to worry with particular reference to illness in general?’, ‘Did the series change viewers’ attitudes towards GPs, hospitals and provincial hospital facilities?’, and ‘How far should a TV series go in dealing with medical matters?’42

Audience issues This chapter aims to outline the triangular territory between biomedicine, relevant moving image media production, and lay people. However, the amount that it has been possible to say about this last category has been decisively limited by the paucity of discussion of this aspect in the extant work, including my own. We have seen reports of accidental eruptions of laboratory medical films into the public sphere, have noted that the proponents of health education films were, up until the 1940s, content with records of audience numbers, and have seen that, with the expansion of the social survey into more aspects of society in the post-war years, it became normal to seek audience opinions of television, at least, in the 1950s. However, as yet there is very little historical work on the impact of biomedical films on how lay people thought about themselves, their health, and medicine. We may ask why this should be. Perhaps the interdisciplinary nature of the work has made authors wary of stepping too far from the mainstream of either history of medicine or film studies. However, if that argument works for history of science, it cannot be said to stand for history of medicine, which has partaken in ‘history from below’ since at least the time of Roy Porter’s Patients and Practitioners and David Armstrong’s medical sociology paper on the doctor–patient relationship three years

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earlier, not to mention Jewson’s influential paper of 1976.43 Perhaps authors assume that doing the history of medical media is the same as doing the history of the public’s attitudes towards medicine. The arguments here rely on an identification between consumers and the media they consume, whereas, as Michel de Certeau pointed out in the 1980s, ‘this misunderstanding assumes that “assimilating” necessarily means “becoming similar to” what one absorbs, and not “making something similar” to what one is, making it one’s own, appropriating or reappropriating it.’44 The work on this reappropriation, and its implications for biomedicine, has yet to be done. For studies of medical films and television to reach their potential, it is important to study audiences. Taking into account all the participants on the historical ground respects all historical actors in a way that is congruent with the development of social history since the beginnings of ‘history from below’, rather than privileging the producers. Moreover, it promises to illuminate the action of biomedical knowledge by asking questions about acceptance, assimilation, and resistance. It can allow us to look at the impact of expansionist biomedicine on the conduct of everyday life and its place in broader culture. But we should proceed with caution. If our motivation for studying audiences is retrospective evaluation of a film’s effectiveness, we are seeking to know what contemporaries did not ask and therefore could not have known. There is also a risk that the experience of audiences may well be beyond capture, both in terms of hard data and in terms of available analytical tools.45 The sources are abundant in the case of production, and weak, dissipated, or problematic in the case of consumption. But recent work on the history of reading, and the turn to studies of use and non-use that have emerged in the history and sociology of technology, strongly suggest that these concerns may not be insurmountable.46

Conclusions The individual films and television programmes I have discussed give insights into the cultures of biomedicine. But what general conclusions can be drawn about how biomedicine ‘looks’ from the standpoint of the study of medical films and television, and how moving image media illuminate the relations among doctors, patients, and the rest of society? Where the cine camera was used as an instrument of medical science, films encapsulated the spirit of experimental medicine and physiology of the late nineteenth century. They were typical of an excitable, young, technomedicine that was keen to apply the techniques of the laboratory, in every form available, to the visualization of physiology and pathology. Patients scarcely featured here and indeed many of the subjects were animals, some of which were—as in the case of the frog’s legs—not even alive. If their makers expected spectators at all other than in published form, the intended audience for these films was other researchers. Of course the occasional leakage into the public realm is interesting. As the film historian Tom Gunning has emphasized, early cinematic

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entertainments were dominated by an ‘aesthetic of astonishment’, and it is easy to see how flexing X-ray frogs’ legs and separating Siamese twins would play with lay audiences.47 But the effect of these films on the public culture of biomedicine was marginal. Later, perhaps starting in 1960 with the compilation film The Revealing Eye, these films began to be included in the texture of documentary and reportage on the history and achievement of biomedicine. This field of medical and cinematic endeavour—both laboratory and clinical—is in need of detailed and sceptical analysis that probes just how significant the cine camera has been to medical science, and why. Health education films encapsulated a cinematic voice of public health. They wore the clothes of mainstream fictional cinema and so they also reinforced hierarchical models of deference to authority, whether based on class or profession, just as they reflected the normally private-sector location of their makers, medical and technical. Within their scenarios, doctors were always treated with significant respect, and the subject position suggested for the viewer was deference to medical authority, encoding the hierarchy of communication in Newman’s policy. We know nothing about the audiences’ actual response to these films; all we can tell is how many attended showings. Comparative work between the health education films produced in different countries is now under way.48 But the study of post-war health education is, as yet, by contrast undeveloped. Early public health documentaries reveal the advocates of biomedical sciences seeking influence on how the health of populations was debated in public. Once again, represented lay people were respectful and deferential, but more the blameless victims of social problems than the careless vectors of disease that we see in the health education films. With Your Life in Their Hands, we see a British medical establishment still adjusting to the dramatic changes in the medical polity brought about by the imposition of the NHS. If these programmes did not bring about a revolution in relations between doctors and lay people, they certainly reveal a crucial change in society more generally. The patients represented remain deferential, but they were being shown and their voices broadcast, and viewers were surveyed for their views on the programmes, on health, medicine, and medical practice. For the first time in the 1950s, there was in the BBC a media organization powerful enough to be the agent in transforming Britain’s public medical culture. It achieved this by virtue of its power to represent what had previously been a private contract between patient and doctor. The histories of medical and public health reportage may fairly be seen as parts of the histories of post-war documentary, which—as it relates to films—is only now beginning to receive serious analysis.49 In studies of television, there is a little more work, notably John Corner’s series of studies on the earlier period.50 However, to gain a clear picture, it will be necessary for both films and television to be explored from the point of view of medical history so as to gain an informed understanding of the interactions between the genre and biomedical culture. A significant lacuna also exists in studies of clinical filmmaking, especially the films made to record, train, and inform doctors. From the film history side of this interdisciplinary space, it will be possible to gain more insights as post-war documentary, which in the Fifties increasingly looked to specialist audiences, is

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studied in more depth. Once again, this will need to be matched by media-sensitive studies of professional training, politics, and culture, if a better picture of these films is to emerge. In sum, the three modes of medical film and television discussed in this chapter stand for different aspects of biomedicine. What they have in common is the confidence of medical expertise and authority, whoever was responsible for the fact that individual films and programmes were made and shown. And audiences, both sick and well, in this period at least, retained their deference to medicine and to doctors. Whether this picture is true, only substantial extra work will show.

Acknowledgements This essay was presented as a keynote address to the Annual Conference of the SSHM, Durham, July 2010; my thanks to the organizers in providing a first opportunity to articulate this argument. It draws on previously published work, including my thesis ‘Films and the Contestation of Public Health in Interwar Britain’ (University of London, 1999), and my ‘Health Education Films in Britain, 1919–1939: Production, Genres and Audiences’, in G. Harper and A. Moor (eds), Signs of Life: Cinema and Medicine (London: Wallflower Press, 2005), 45–57.

Notes 1. Roy Porter, Bodies Politic: Disease, Death and Doctors in Britain, 1650–1900 (London: Reaktion Books, 2001); Sander Gilman, Health and Illness: Images of Difference (London, Reaktion Books: 1995); Roger Cooter and Claudia Stein, ‘Coming into Focus: Posters, Power, and Visual Culture in the History of Medicine’, Medizinhistorisches Journal, 42 (2007), 180–209. 2. Anne Karpf, Doctoring the Media: The Reporting of Health and Medicine (London: Routledge, 1988). 3. Susan E. Lederer and Naomi Rogers, ‘Media’, in Roger Cooter and John Pickstone (eds), Medicine in the Twentieth Century (Amsterdam: Harwood Academic, 2002), 487–502. 4. Michael Shortland (ed.), Medicine and Film: A Checklist, Survey and Research Resource, Research publication no. 9 (Oxford: Wellcome Unit for the History of Medicine, 1989), initiated research in this field. 5. G. Harper and A. Moor (eds), Signs of Life: Cinema and Medicine (London: Wallflower Press, 2005). 6. Leslie J. Reagan, Nancy Tomes, and Paula A. Treichler (eds), Medicine’s Moving Pictures: Medicine, Health, and Bodies in American Film and Television (Rochester, NY: University of Rochester Press, 2007). See my review in Medical History, 53 (2009), 295–7. 7. Brian Glasser, Medicinema—Doctors in Film (Oxford: Radcliffe, 2010). 8. For a recent example, see R. Wall and A. M. Rafferty. ‘Film Review: Nurse Edith Cavell’, Medical Humanities, 35 (2009), 127–8.

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9. Kirsten Ostherr, Cinematic Prophylaxis: Globalization and Contagion in the Discourse of World Health (Durham, NC: Duke University Press, 2005). 10. Joseph Turow, Playing Doctor: Television, Storytelling, and Medical Power (Ann Arbor: University of Michigan Press, 2010). 11. Rachael Low, Documentary and Educational Films of the 1930s (London: Allen and Unwin, 1979); eadem, Films of Comment and Persuasion of the 1930s (London: Allen and Unwin, 1979); Frances Thorpe and Nicholas Pronay, British Official Films in the Second World War (Oxford: Clio Press, 1980). The BFI database, while patchy, is an indispensable data source: http://ftvdb.bfi.org.uk/searches.php 12. Rima Apple and Michael Apple, ‘Screening science’, Isis, 84 (1993), 750–74; Christopher Lawrence, ‘Cinema Vérité?: The Image of William Harvey’s Experiments in 1928’, in N. Rupke (ed.), Vivisection in Historical Perspective (London: Croom Helm, 1987), 295–313; Geoffrey Crothall, ‘Images of Regeneration: Film Propaganda and the British Slum Clearance Campaign, 1933–1938’, Historical Journal of Film, Radio and Television, 19 (1999), 339–58; David Cantor, ‘Uncertain Enthusiasm: The American Cancer Society, Public Education, and the Problems of the Movie, 1921–1960’, Bulletin of the History of Medicine, 81 (2007), 39–69; Michael Clark, ‘ “A Bill of Divorcement”: Theatrical and Cinematic Portrayals of Mental and Marital Breakdown in a Dysfunctional Upper-Middle Class Family, 1921–1932’, in Mark Jackson (ed.), Health and the Modern Home (London: Routledge, 2007), 21–41. 13. Martin S. Pernick, The Black Stork: Eugenics and the Death of ‘Defective’ Babies in American Medicine and Motion Pictures since 1915 (New York: Oxford University Press, 1999). 14. Ulf Schmidt, Medical Films, Ethics and Euthanasia in Nazi Germany: The History of Medical Research and Teaching Films of the Reich Office for Educational Films/Reich Institute for Films in Science and Education, 1933–1945 (Husum: Matthiesen Verlag, 2002). 15. Medicine is not a particular focus, except where contemporaries defined it as science. 16. Ian Christie, The Last Machine: Early Cinema and the Birth of the Modern World (London: BBC Educational Developments, 1994); Virgilio Tosi, Cinema before Cinema: The Origins of Scientific Cinematography, trans. Sergio Angelini (London: British Universities Film and Video Council, 2005); J. W. Douard, ‘E-J Marey’s Visual Rhetoric and the Graphical Decomposition of the Body’, Studies in the History and Philosophy of Science Part A 26 (1995), 175–204. 17. Lisa Cartwright, ‘ “Experiments of Destruction”: Cinematic Inscriptions of Physiology’, Representations, 40 (1992), 129–52; eadem, Screening the Body: Tracing Medicine’s Visual Culture (Minneapolis: University of Minnesota Press, 1995); Luke McKernan, Who’s Who of Victorian Cinema: A Worldwide Survey, available at http://www.victorian-cinema.net/ watkins.htm; M. Essex-Lopresti, ‘Centenary of the Medical Film’, The Lancet, 349 (1997), 819–20. 18. Hannah Landecker, ‘Microcinematography and the History of Science and Film’, Isis, 97 (2006), 121–32, 123. 19. Cartwright, Screening the Body, 54–60. 20. Christie, The Last Machine, 100. 21. Cartwright, ‘Experiments of Destruction’, 132. 22. George Newman, Public Education in Health, 2nd edn (London: HMSO, 1925), 4. 23. Ibid. 17–18. 24. Timothy Boon, ‘Films and the Contestation of Public Health in Interwar Britain’, unpublished PhD thesis, University of London, 1999, Chapter 4.

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25. Elizabeth Lebas, ‘ “When Every Street Became a Cinema”: The Film Work of the Bermondsey Borough Council’s Public Health Department’, History Workshop Journal, 39 (1995), 42–66. 26. Boon, ‘Films and the Contestation of Public Health’, 187–90. 27. T. Boon, ‘The Nation’s Health’, in D. Brunton (ed.), Medicine and Society in Europe, 1500– 1930: Study Guide 2 (Milton Keynes: Open University, 2004), 66–70. Annette Kuhn’s account of the sub-genre of VD films provides valuable analysis: Annette Kuhn, Cinema, Censorship and Sexuality, 1909–1925 (London: Routledge, 1988). 28. J. Richards, The Age of the Dream Palace (London: Routledge, 1984); Central Council for Health Education (ed.), Health Education Year Book (London: Central Council for Health Education, 1939), 111; W. Allen Daley, ‘The Organisation of Propaganda in the Interests of Public Health’, Public Health (September 1924), 305–13. For discussion of costs of production, see Boon, ‘Films and the Contestation of Public Health’, 177–8. 29. One American exception to this rule is quoted by Lederer and Rogers, ‘Media’. 30. Mariel Grant, Propaganda and the Role of the State in Inter-War Britain (Oxford: Oxford University Press, 1994). 31. For a detailed account of this film and its context, see Timothy Boon, Films of Fact: A History of Science in Documentary Films and Television (London: Wallflower Press, 2008), Chapter 3. 32. Ibid. Chapters 4, 5, 6, and 7. 33. Thorpe and Pronay, British Official Films, 173. 34. Ralph Desmarais, ‘ “Promoting Science”: The BBC, Scientists, and the British Public, 1930–1945’, MSc dissertation, University of London, 2004. 35. Elaine Bell, ‘The Origins of British Television Documentary: The BBC 1946–55’, in J. Corner (ed.), Documentary and the Mass Media (London: Edward Arnold, 1986), 65–80, 68–9. 36. Boon, Films of Fact, 213–14. 37. Kelly Loughlin, ‘ “Your Life in Their Hands”: The Context of a Medical-Media Controversy’, Media History, 6 (2) (2000), 177–88, at 178. 38. Anon, ‘Disease Education by the BBC’, British Medical Journal (1 March 1958), 510–11. 39. Norman Swallow, Factual Television (London: Focal Press, 1966), 147–8. 40. BBC WAC file T14/1, 833. 41. Ivan Waddington, ‘The Role of the Hospital in the Development of Modern Medicine: A Sociological Analysis’, Sociology, 1 (1973), 11–224. 42. An Enquiry into the Effects of the Television Series ‘Your Life in Their Hands’ Broadcast between February and April, 1958, November 1958, BBC WAC, S322/207. 43. R. Porter (ed.), Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society (Cambridge: Cambridge University Press, 1985); D. Armstrong, ‘The DoctorPatient Relationship: 1930–1980’, in P. Wright and A. Treacher (eds), The Problem of Medical Knowledge: Examining the Social Construction of Medicine (Edinburgh: Edinburgh University Press, 1982), 109–22; N. Jewson, ‘Disappearance of the Sick-Man from Medical Cosmologies, 1770–1870’, Sociology, 10 (1976), 225–44. 44. Michel de Certeau, The Practice of Everyday Life (Berkeley: University of California Press, 1984), 166. 45. For one approach, see T. Boon, ‘Lay Disease Narratives, Tuberculosis and Health Education Films’, in Flurin Condrau and M. Worboys (eds), Tuberculosis Then and Now: Perspectives on the History of an Infectious Disease (Montreal: McGill-Queens University Press, 2010), 24–48.

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46. Nelly Oudshoorn and Trevor Pinch (eds), How Users Matter: The Co-Construction of Users and Technologies (Cambridge, MA: MIT Press, 2003); Jonathan Rose, The Intellectual Life of the British Working Classes (New Haven, CT: Yale University Press, 2001). 47. Tom Gunning, ‘An Aesthetic of Astonishment: Early Film and the (In)credulous Spectator’, in L. Braudy and M. Cohen (eds), Film Theory and Criticism: Introductory Readings (New York: Oxford University Press, 2004), 862–76. 48. Christian Bonah and Anja Laukötter, ‘Moving Pictures and Medicine in the First Half of the 20th Century: Some Notes on International Historical Developments and the Potential of Medical Film Research (Essay Review)’, Gesnerus, 66 (1) (2009), 121–46. 49. Patrick Russell and James Taylor (eds), Shadows of Progress: Documentary Film in PostWar Britain (London: BFI/Palgrave, 2010). 50. J. Corner (ed.), Popular Television in Britain: Studies in Cultural History (London: British Film Institute, 1991).

Select Bibliography Bonah, Christian, and Anja Laukötter, ‘Moving Pictures and Medicine in the First Half of the 20th Century: Some Notes on International Historical Developments and the Potential of Medical Film Research (Essay Review)’, Gesnerus, 66 (1) (2009), 121–46. Boon, Timothy, Films of Fact: A History of Science in Documentary Films and Television (London: Wallflower Press, 2008). —— , ‘Lay Disease Narratives, Tuberculosis and Health Education Films’, in Flurin Condrau and M. Worboys (eds), Tuberculosis Then and Now: Perspectives on the History of an Infectious Disease (Montreal: McGill-Queens University Press, 2010). Cartwright, Lisa, ‘ “Experiments of Destruction”: Cinematic Inscriptions of Physiology’, Representations, 40 (1992), 129–52. Harper, Graeme, and Andrew Moor (eds), Signs of Life: Cinema and Medicine (London: Wallflower Press, 2005). Karpf, Anne, Doctoring the Media: The Reporting of Health and Medicine (London: Routledge, 1988). Kuhn, Annette, Cinema, Censorship and Sexuality, 1909–1925 (London: Routledge, 1988). Lebas, Elizabeth,‘ “When Every Street Became a Cinema”: The Film Work of the Bermondsey Borough Council’s Public Health Department’, History Workshop Journal, 39 (1995), 42–66. Loughlin, Kelly, ‘ “Your Life in Their Hands”: The Context of a Medical-Media Controversy’, Media History, 6 (2) (2000), 177–88. Pernick, Martin S., The Black Stork: Eugenics and the Death of ‘Defective’ Babies in American Medicine and Motion Pictures since 1915 (New York: Oxford University Press, 1999). Reagan, Leslie J., Nancy Tomes, and Paula A. Treichler (eds), Medicine’s Moving Pictures: Medicine, Health, and Bodies in American Film and Television (Rochester, NY: University of Rochester Press, 2007).

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Index

Ābādi, Allâh 180 Abbasids 172, 173, 174, 179 Abd al Mālek b. Habib, see Bin Habib, Abd al Mālek Aberdeen Child Development Survey 128 Aberdeen typhoid epidemic (1964) 609 Aborigines 306–7, 307–8, 310 abortion 234, 235, 508, 518, 519 abscesses, lancing 161, 178 accident insurance 436 acclimatization 89 Ackerknecht, Erwin 415, 416 acquired immune deficiency syndrome, see AIDS Acton, William 507, 509 acupuncture 152, 153, 154, 161, 192, 268, 578, 581, 583, 584–6, 590–1 Adams, Mark B. 212 adaptation 190, 478, 533–4 Adler, Alfred 532 adolescence 325, 329, 330–1, 496 adulteration of food and drink 91 advertising 85, 545, 546, 547 aetiology 181, 525, 530, 532, 535 Aetius 61 Africa 140, 143, 228, 266–80, 275, 278, 309, 513, 603, 610, see also South Africa African-Americans: midwives 487 sickle cell anaemia 234–5 Tuskegee Syphilis Experiment 120, 235, 414, 421, 548, 551, 609, see also United States ageing process 338–9, 342–5, see also old age agricultural revolution 200 agriculture 257, 377, 415, 566

agrobiology 212–13 AIDS (acquired immune deficiency syndrome) 11, 109, 111, 117–19, 233, 380, 393–4, 424, 458 Africa 120, 266, 513–14 contemporary history of 124 lifestyle and 513–14, 519 oral testimony of doctors 600 treatment testing 551 venereal disease and 513 air: eighteenth-century experimentation 88–9 fresh 201, 348, 361, 451, 462–3, 528 microorganisms in 202 pollution 180, 458 travel 138, 147 n.14 akrasia 34–5 Albucasis (al-Zahrâwi) 177, 178–9 Albury, Randolph 305 alchemy 24, 42, 62, 66, 157, 197, 285 alcohol 197, 422 alcoholism 215 Alder Hey Children’s Hospital, London 553 Alderotti, Taddeo 42, 47 Alexander, Franz 533 Alexander of Macedonia 172 Alexander of Tralles 176 Alexandria 172, 174 medical schools 28, 41, 42, 55, 173, 175, 563 quarantines 290 Ali b. Reza, see Bin Reza, Ali alienists 472, 526, 529, see also psychiatry Alison, William Pulteney 382 Allbutt, T. C. 490 Allende, Salvador 258, 259–60 allergies 461, 494 allopathy 249, 250, 251, 257, 586



index

alternative medicine 490–1, 578–92 chiropractic 228, 578, 581, 588, 592 herbalism 84, 246, 250, 279, 491, 580, 586 homoeopathy 249, 250, 546, 578, 581, 585, 586, 588, 589, 590, 592 in India 288 osteopathy 228, 578, 587, 588 in South Asia 285, see also folk medicine; spirits/spirit healing Alvorn, J. L. 347 Alzheimer, Alois 345 Amār b. ‘Ali of Mosul, see Bin ‘Ali of Mosul, Amār American Civil War (1861–5) 107 American Medical Association 231, 232, 544, 545, 546, 547 American Psychiatric Association 511, 537 American Psychological Association 531 amnesia 46, 530 amputation for punishment 178 amulets 48, 49, 193 Amulree, Lord 404 anaesthetics 155, 161, 203, 624 anal fistula 199 anatomy 41, 67, 171, 472, 584 Aristotle and 175 comparative 563–5 Galenic theories of 28, 63, 65 human sexual 505–6 Islamic 170, 176–8, 176–9 lectures on 198 materialism and 198 Anatomy Act (1832) 362–3 Anderson, Ian 305, 306 Anderson, Margo 236 Anderson, Warwick 304, 307, 310, 311–12 Andrews, Jonathan and Digby, Anne 491 Andrews, Thomas G. 457 Angelova, Milena 215 Anglo-Saxon pharmacopoeia 193 animal behavioural studies 572 animal dissection 176–7, 178, 563 animal experimentation 549, 550, 567–70 animal magnetism 90, 528, 585 animal medicine, see veterinary medicine animism 176, 199 anovulation 385

antenatal diagnostics 234 anthelminthics 192 anthrax 202 anthropology 7, 25, 217, 277, 278, 307, 332–3, 358, 373, 420, 431, 581, 610 antibiotic resistance 380 antibiotics 401, 424, 517, 571 anti-depressants 535, 537, 538 Antioch 172 antiquarianism 62 anti-rabies vaccine 250 anti-retroviral therapy 266, 274, 277, 278 antitoxins 569 anti-vivisection movement 549, 567 Antoine, Duke of Lorraine 66 anxiety 111, 113, 329, 330, 331, 356, 358, 361, 366, 397, 494, 495, 509, 513, 516, 535, 602 apothecaries 3, 47, 62, 83, 84, 85, 89, 195, 196, 197–8, 472, 544 Apple, Rima 495 ‘appropriate consent’ 553 ‘Aqīlī, Mohammad-Hosein 175, 182, 183 Arabia 160, 170, 176, 270 Arabic language/translations 22, 41, 45, 55, 60, 65, 161, 173–4, 176, 183, 194, 196, 197 Archiagathus 192 Argentina 252, 253, 256, 257, 258, 260, 261 Ariès, Philippe 325, 359–60, 367, 378 Aristotle 24, 26, 30, 41, 44, 61, 64, 342, 343, 348 human-animal analogy 563 Islamic medicine and 172, 173, 175, 177, 178 on mental health 33–5 theory of the four elements 471 Armstrong, David 627 Armstrong, Dr W. C. 313 Arnald of Villanova 43, 46, 47 Arnold, David 288–9, 291, 293, 302 Arrowsmith (Lewis and de Kruif) 414 arsenic 157 arthritis 402 artificial limbs 108 artificial respiration 553–4 asbestos/asbestos-related disease 270, 453, 454, 603 Asclepiades of Bythnia 30, 192 Ashford, Bailey 255

index ASHM (Australian Society of the History of Medicine) 304 Aspasia (journal) 214 As-Ṣanowbary 181 As-Suyūṭī, Abd ar-Raḥmān 181 asthma 234, 461 astrology 24, 42, 62, 66, 80 n., 84, 152, 173 astronomy 63, 153–4, 155 astro-physiology 150 asylums 435, 491, 528–9, 530, 537, 550 colonial Australia and New Zealand 313–14 India 293–4 Magdalene 507 oral testimony of 604 atheism 24, 199 atherosclerosis 344, 422 attention deficit hyperactivity disorder 331 Attewell, Guy 287 Augustine, Saint 50 Augustus, Elector of Saxony 66 auscultation 92, 397 Australia 302–14, 586 Austria 203, 325 autopsy 63, 68, 92, 198, 399, 565 Averroes (Ibn Rushd) 61, 174 Avicenna (Ibn Sina) 41, 44, 55, 61, 171, 174, 177, 184, 194, 471 ayurveda medicine 22, 56, 60, 183, 285, 287, 288, 592 Aztecs 245, 247

Babylonian medicine 24, 26 Bachelard, Gaston 477–8 Bach Flower remedies 580 Bacon, Francis 62, 67, 348 Bacon, Roger 40 bacteriology 230, 249, 252, 398, 413, 414, 472, 549, 568, 569 Badiano, Juan 247 Baer, Hans 589 Baghdad 172, 179, 582 Baglivi, Gjuro (Giorgio) 90 Bailles, Kendall E. 210 Baker, Robert 543, 545 Baldwin, Peter 120, 433



Balint, Michael 536 Banda, Hastings Kamuzu 273 Bangladesh 139, 140, 142, 143 Banting, Frederick 400 Banu, Gheorghe 214 Baran, Britta 216 barber-surgeons 62, 65, 85, 195 Barker, David 384 Barker-Benfield, G. J. 488 Barnes, E. 329 Barnes, Sandra T. 269 Basel 66 Bashford, Alison 302, 309, 310, 311, 487 Batavia 583 Bates, Don 592 bathing 182 Bayer, Ronald and Oppenheimer, Gerald 600 BBC (British Broadcasting Corporation) 624, 625–7 BCG vaccination 122, 549 Beard, George Miller 102–3 Beck, Aaron 536 bedwetting 330 Beecher, Henry 551 Beier, Lucinda McCray 602 Belgium 203, 429 Benedek, László 216 Benedictines 194 Benison, Saul 600–1 Bentham, Jeremy 420–1 bereavement 357, 358, 359, 360, 368, see also death Berger, John 561 beriberi 252 Berlant, Jeffrey and Waddington, Ivan 544, 545 Bermondsey Borough Council, London 621 Bernard, Claude 567–8 Bernheim, Hippolyte 530 Berridge, Virginia and Strong, Philip 11 Best, Charles 400 Betts, Alan 572 Bevan, Aneurin 433, 440 Beveridge Report (1942) 440 Bhattacharya, Sanjoy 292 Bhophal disaster (1984) 460 The Bible 170, 338, 340 bile 29, 30, 32, 342



index

Bin ‘Ali of Mosul, Amār 178 Bin Habib, Abd al Mālek 180 Bin Jazlah, Yahya b. Isā 179 Bin Qurra, Sinān b. Thābit 180 Bin Reza, Ali 181 bio-archaeology 27 bioethics 543, 552–4 biological death 355–6 biological sciences 421, 472 biomedicine 8, 24, 25, 119, 183, 191, 257, 270, 435, 562, 568, 571, 580, 582, 588, 599, 602 alternative medicine and 581, 585, 587, 591 colonialism and 305, 310 culture and 617, 618, 627, 628–30 ethics and 606, 607, 608 interventionist bias of 42 public health and 620 public responses to 554 in United States 231 universality 109, 579 biotechnology 231, 554 Bíró, Judit 215 birth control 494, 509 birth control clinics 493 birth rate decline 345, 378, 508 Bismarck, Otto von 429, 431, 436 Black, Sir Douglas 125 Black Death 53–4, 65, 176, 196, 385, 387 Black Report (1980) 122, 125 Blair, Tony 446 Bland, Tony 554 blindness 402 Blok, Gemma 331 blood 342, 533 ancient medicine and 29, 32, 34 cholesterol 402 circulation 65, 102, 177–8, 198, 199, 471, 564 corpuscles 620 haemophilia 599 samples 567 sugar 400 tests 249, 476, 525 transfusion 572 typing 203 blood-letting 42, 154, 161, 177, 227, 565, 566 Boas, Ernst P. 403–4

body: in Chinese medicine 152, 153–4, 155, 156, 162–3 developing 329 in early modern era 62, 67–8 in eighteenth-century medicine 83, 87–9 female 486, 488, 492 Foucault on the 82, 112 in Graeco-Roman medicine 24, 33, 34 heterodoxy 582–3 materialism and 198–9 mechanistic view of the 90, 102, 108, 478 modernity and 101, 111 body rhythms 603 body weight 109, 121 Boerhaave, Herman 92, 199, 472 Boer War 436 Bolivar, Simon 243 Bolivia 248, 253, 257, 261 Bologna, University of 66, 195, 198, 471 Bolshevik Revolution (1917) 210 bones 70, 71, 171 disease 344, 347 osteoarchaeology 70 osteopathy 228, 578, 587, 588 bone-setting 170, 177, 178, 194, 285 Bonner, Thomas 229 Boon, Timothy 619 Boqrāt thāni 175 Bosnia 214 botanical gardens 63, 67, 197, see also medicinal plants botany 67, 477, 491 Botswana 278, 603 Bourdieu, Pierre 244 Bousfield, Guy 621 Bowlby, John 360 Bowring, Richard 279 Boxer Uprising (1900) 162 Boyle, Robert 572 brain 32, 199, 345, 534 brain death 356, 553 Branca, Patricia 494 Brandt, Allan 126, 460 Bratescu, Gheorge 216 Braun, Ludwig 620 Braunstein, Jean-François 477

index Brazil 140, 243, 246, 247, 248, 249, 251, 252, 253, 255–6, 257, 258, 260, 261, 341 breastfeeding 245, 595 breathing techniques 156 Breinl, Anton 309 Brenko, Aida 214 Breuer, Joseph 531 Bright, Richard 399, 400 Brimblecombe, Peter 458 Briscoe, Gordon 307 Bristol Royal Infirmary 553 Britain: bioethics 553, 554 cemeteries in 366 chronic illness 404–5 contemporary history of medicine 119, 123 debilitated state of army recruits 402, 436 epidemiology 382 Freedom of Information Act 123–4 geriatric care in 341, 345 global smallpox eradication programme 140 health education films 620–3 History and Policy partnership 127 homosexuality 510, 511 industrial health 453, 454 life expectancy 341, 381–2 medical ethics 546–7, 551 medical profession 203 national health insurance 203, 429, 430, 436, 437 oral history 598, 600 organ transplants 553 population health indicators comparison 444–6 pre-welfare state 434–5 public health 121 punishment of professional misconduct 547 Reform Acts 432 ‘revolution in government’ 417 Salk polio vaccine 122 study of women’s childbearing history 378 veterinary profession in 571–2 welfare state 432, 439–40, 442, see also NHS (National Health Service)



British Insurance Act (1911) 231 British Medical Association 433, 437, 546–7, 626 British Medical Journal 313, 516, 572, 626 British Psychological Association 531 British Social Hygiene Council 622 Brodum, William 348 bronchitis 384 Brookes, Barbara 314 Brown, Louise 554 Brown, Phil 460 Brown, Richard 421 Bryder, L. 122 BSHM (British Society for the History of Medicine) 3, 4 bubonic plague 383–4 Buchan, William, Domestic Medicine 86, 328 Bucur, Maria 216 Buda, Octavian 215 Buddhism 157–8 Buell, Paul D. 161 Bulgaria 209, 214, 215, 377 Buller, Sir Arthur 125 Bulletin of the History of Medicine 119 bureaucracy 104, 106, 108, 151, 159, 195, 200 burial practices 27, 356, 358, 362, 363, 365–8, 376, 434, see also death Burke, Gillian and Richardson, Peter 272 Burma 293 Burnham, John C. 458 Burrow, Trigant 532 Bursa 174 Burton, Robert, Anatomy of Melancholy 72 Burtt, E. A. 524 Busby, Helen 609 Busfield, Joan 491 Bush, Vannevar 229 Butler, Josephine 512 Bynum, William 1–2, 3, 569, 588 Byron, Lord 365 Byzantium 55, 170, 173

cadavers 362–3 Cade, John 536 Caelius Aurelianus 29 Caius, John 68

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index

Calcutta Medical College 287 Calloway, Colin 226 Calvo, Marco Fabio 80 n. CAM (complementary and alternative medicine) 581, see also alternative medicine Cambridge Group 373, 380, 418 Canada 190, 306, 307, 384, 600 Canadian International Development Agency 140 cancer 293, 380, 394, 402, 460 animals and 571 environmental causation of 461 memoirs 406 mortality and survival rates 446 terminal care 364 young patients 329 Canguilhem, Georges 471, 477–9, 568 Cannadine, David 367 Cannon, Walter 533 Canstatt, Carl 344 Cantor, David 122–3, 619 carcinogens 422, 423 cardiology 108, 121, 157, 236, 342–4, 394, 402 cardiovascular disease 380, 402, 403, 404 cardiovascular drugs 401 Carel, Havi 405 Carr, E. H. 5, 7, 9 Carson, Rachel 462 Cartesianism 63, 65, 102, 199 Cassiodorus 193 castration 161 cataract surgery 161, 295 Catholic Church 259, 271, 277, 552 ‘artificial’ birth control 508 early modern medicine 61 a ‘good death’ 357, 358 medical provision in Latin America 246, 249, 252, 258, 259, see also missionaries/ missionary medicine cauterization 154, 170, 171, 197, 585 Cawston, Richard 625 ‘Celestial Bed’ (electrified bed) 90 cellular pathology 202 Celsus 29, 61, 192 cemeteries 365–6, see also burial practices censuses 236, 375, 376, 383

centralization 91–2, 104, 173, 419 Certeau, Michel de 628 cervical screening 519 Chaco War (1930s) 257 Chadwick, Edwin 201, 366, 418–19 Champier, Symphorien 66 Chandavarkar, Raj 289 Charcot, J. M. 344, 526 charity/charitable organizations 91, 104, 249, 363–4, 430, 484 charity hospitals 246, 249, 252, 256, 295 charlatans 62, 65, 246 Charles I, King of England 66 Charles IV, King of Spain 248 Charles VIII, King of France 66 charms 47, 48, 156, 193, 199 Chatterton, Thomas 365 Chavunduka, Gordon 275 chemistry 202, 472 Chernobyl 460 Chester, Phyllis 491 Chevalier, Louis 420 Chiarugi, Vincenzo 528 child abuse 324–5 childbirth 485 Africa 275 Latin America 245, 247 ‘male takeover’ of 492–3, 495 oral testimony 605–6 child death 357–8 child development 273, 330, 415 child guidance movement 330 childhood 321–33, 324–5, 329–31, 496 childrearing 488 children: abandoned 91 ban on experiments on 550 chronic illness and 402 diabetes and 400 lead poisoning and 458 medicine 334 n.19 child welfare 212, 215, 313, 322, 323, 484 Chile 248, 253, 256, 258, 259–60, 261, 377, 383, 454 China 150–64, 259, 276, 277, 384, 582, 584 body and 162–3 cultural exchanges 160–2

index European anatomical texts available in 161 famines in 385 herbal medicine 586 mythic origins of 151–6 religion and 156–8 Song government politics and 158–60 Westernization 162, see also acupuncture china root 175, 186 n.48 Chinese medicine 22, 56, 60, 583, 590, 592 Chinese migrants 233, 251, 314 Chinese prisoners of war 551 chiropractic 228, 578, 581, 588, 592 chloroform 161, 486 chlorpromazine 534, 536 cholera 200, 202, 226, 227, 233, 235–6, 253, 254, 568 India 288–90 Islamic medicine and 175 John Snow and 201 Latin America 250 magic and 176 public health and 419–20 Christianity 170, 190, 193 African medicine and 270–1 death and 356, 357, 367 medieval medicine and 49–50 morality 544 Reformation 196 in Roman Empire 29 Christianization 172–3 Christian Science 587, 588, 592 chronic illness 384, 393–406, 460 consumption 395–8 epidemiology and 236, 293, 394–5, 402, 403, 404, 406, 460 nursing 435 welfare reform and 401–5 Cilento, Sir Raphael 310, 312 cinematography 619–20, 628 cinnabar 157 cities: American 227 environmental history of 457–8 Latin American 248–9 mortality in 382 quarantine measures 196, 233 sanitation 247–8, 250

citizenship rights 195 Clark, David 364–5 Cleland, Professor John Burton 308 climate, and disease 31, 88–9, 293 clinical medicine 175, 180 chronic illness and 398, 399 drug treatments and 121, 401 eighteenth-century 92–3 Islamic 175, 178, 180 laboratory methods and 202, 229, 399 modernity and 105, 107, 108, 111 public health and 414, 450 United States 229, 231 clinical psychology 524, 533, 535–8 clinical trials 119, 121, 536, 538, 620 Clinton, President Bill 443 clitoridectomy 488, 507 cloning 554 Clot-bey, Dr 183 cloves 193 Cody, Lisa 492 cognitive psychology 535–6 Cold War 190 Coleborne, Catharine 314 Coleridge, Samuel Taylor 527 Colgrove, James 380 collective memory 118, 278, 306, 608–10 collective tradition 191, 195, 200 Colombia 248, 251, 252, 255, 257, 258 colonialism 190, 200, 243, 271, 302 colonial medicine 89, 230, 270, 307–8, 421, 581 acclimatization 459 in Africa 271–3, 275–6 in India 286–96 in Latin America 245–6, 245–8 local knowledge and 583–5 Maoris 306 mental health and 313–14 oral history and 603, 604 in sub-Saharan Africa 266 Comaroff, John and Jean 272 commentary literature 174–5 commodification 83, 90, 230 communism 211, 213, 214 complementary medicine, see alternative medicine

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

index

complexion diagnosis 41, 44, 46, 48, 162–3 compound drugs 171, 179 Condorcet, Marquis de 348 Condrau, Flurin and Worboys, Michael 373 confidentiality 545, 548, 607 Confucianism 152 Congo 275 Conroy, Mary Schaeffer 211 consciousness 32, 157, 355, 530 consent forms 606–7 Constantinople 290 Constantinus Africanus 194 consumption 394, 395–8, 405, see also tuberculosis Contagious Diseases Acts 294, 513, see also infectious diseases contraception 120, 121, 122, 377, 378, 496, 508, 518, 519 convulsive treatments 534 Cook, Harold C. 473 Cooper, David 538 Cooter, Roger 8–9, 552, 588, 618 In the Name of the Child 321, 322, 331–2 Cooter, Roger and Pickstone, John, Medicine in the Twentieth Century 2–3, 8, 119 Copernican Revolution 63 Copp, Wilhelm 68 Corbin, Alain 459 Cornarius, Janus 68 Cornaro, Alvise 347 Cornaro, Luigi 348 Corner, John 629 Cornwall, Jocelyn 602 corporations 191, 194–200, 204–5 Cortés, Hernán 245 Coslett, Tessa 605 cosmetic psychiatry 537 cosmetic surgery 484 cosmology 157, 172, 584, 588 Costa Rica 244, 251, 257, 260 Counter-Reformation (1555/60–1689) 61 court physicians 33–4, 62, 66, 160, 179–80, 183, 199 Courtwright, David 126 Cowdry, E. V. 345 cowpox 199, 248, 566–7

Craddock, S. 458 cremation 366–7 Crimean War (1853–6) 201 criminal anthropology 103, 217 Criminal Law Amendment Act (1885) 510 Croatia 214 Crosby, A. W. 456, 610 cross-cultural medicine 580–1, 582, 583, 586, 587, 590, 591, 592 Crothall, Geoffrey 619 Crowther, Anne 313 Cruelty to Animals Act (1876) 570 Cruz, Martin de la 247 Cuba 243, 244, 248, 253, 258, 259, 260, 261 Cule, John H. and Lancaster, John M. 212 Cullen, William 527 cultural history 7, 8, 128, 277, 311, 456, 478, 555, 564, 598 ancient world 26, 27, 35 of death 406 early modern medicine 66–7 eighteenth-century 82 heterodox medicine 579 old age 349, 350 cultural identity 29, 610 Cumpston, Dr J. H. L. 313 Cunningham, Hugh 333 cupping 170, 181 Curl, James 365 Curth, Louise Hill 565 cybernetics 53–34 cystic fibrosis 234 cyst removal 161 cytology 472 Czechoslovakia 209 Czech Republic 118 Czeizel, Endre 216

Dale, Sir Henry 569 Daley, Allen 622 Dally, Ann 547 Daniel, Pete 460 Daoism 156, 157–8 Darwin, Charles 216, 348, 472, 530 data protection 124, 606–8 Data Protection Act (1989) 601

index dates (fruit) 170 Datini, Francesco and Margherita 48–9, 54 Davies, Kerry 605, 608 Davis, Angela 495–6 Davis, Anne 399 Davis, Mike 458 Day, George 344 DDT pesticide 258, 460, 462 deafness 402 death 355–69 African rituals of 278–9 biological and spiritual definitions of 355–6 brain 356, 553 burial practices 27, 157, 356, 358, 360, 362, 363, 365–8, 376, 434 cultural history of 406 ‘good’ 356–9 at home 367 palliative care 361 and the poor 362–3, 363, 366, 368 secularization of 359–60, 362, 363 suicide 273, 358, 532 twentieth-century management of 360, see also religion Declaration of the Rights of Man 93 Defence of the Realm Act (1918) 513 degeneration 102, 103, 114, 310, 330, 344, 378, 383, 510, 514, 530 delinquency 331 Dembe, Alan 452 democracy 190, 413, 432 demographic studies 31, 341, 355 demographic transition theory 377, 378, 379, 380 demography 200, 373–87, 406, see also population Deniker, Henri 536 Denmark 120, 140, 203, 384, 429, 487 Denoon, Donald 312 depression 395, 496, 535 childhood 325 clinical 525 old age 339 women and 602 Derickson, Alan 453 Descartes, René 63, 65, 102, 199



De Secretis Mulierum 346 Deshima medics 590 Deverell, William 458 Dewey, Scott Hamilton 458 diabetes 261, 293, 384, 399–401 Diack, Lesley 609 diarrhoea 88, 157, 382 diet 33, 34, 42, 121, 156, 171, 180 and adult height outcomes 322 animal 565 childhood 323 ‘exotic’ foodstuffs introduced to 89 junk food 422 nutrition 415, 623 old age 347, 348 sacred 170 studies 422 therapies 399 Digby, Anne 493 al-Din, Vizier Rashid 160 Dinges, Martin 492 Diocles of Carystus 24, 26, 28 Dioscorides 51, 52, 61, 171, 193 diphtheria 108, 383, 621 disability 107–8, 278, 455 disciplinarity 526 disease(s) 27 childhood 326, 327, 357, 382 climate and 31, 88–9, 293 crowd 227 degeneracy and 233, 363, 413 ‘diagnosis’ of historical 53–4 food production and 571 of old age 342, 344–5, 347 plurality of attitudes to 25–6 political economy of 272, 275, 279 poverty and 201 prevention 86–7 racially-based theories of 232–5, 272, 383–4 science-based public health and 413 society and 235–6 surveillance regimes 91, 138, 139, 260, 419, 421 women’s 85, 489, see also germ theory of disease; infectious diseases dispensaries 286, 321, 327, 328 for the poor 294, 295, 363 Disraeli, Benjamin 432



index

dissection 21, 563, 564 ancient Chinese 154–5 animal 176–7, 178, 563 Arabic translations of 176–7 cadavers for 363 Islam and 178 medieval 198, see also human dissection; vivisection distemper 564 divination 30–1, 84, 150, 152, 156, 246, 250 Divine Farmer (Red Emperor) 152 Dobson, Matthew 399 Dobyns, Henry 226 doctors, see under physicians Doerner, Klaus 528 dogs 566, 568 Doll, Richard 404 Dolling, Father 357 domestic animals 566 Dominican Republic 243 Dow, Derek A. 306, 307, 311, 314 Doyen, Dr Eugène-Louis 620 Drachman, Virginia 490 dropsy 199, 399, 400 druggists 65, 89 drugs 194, 227 anti-depressants 537 Chinese medicine 152 compound 171, 179 contemporary history 124 illicit 119, 120–1 mental illness 121, 534–5, 536, 537 South Asia 285 veterinary 565 Dubos, Jean and Dubos, René 395, 396, 405 Duden, Barbara 82, 459 Dufferin Fund 295 Duffy, John 419 Dugac, Željko 214 Dunbar, Helen Flanders 533 Duncalf, Bill 625 Dunham, Warren 533 Dun Huang texts 56, 160 Dupree, Marguerite 313 Durey, Michael 419 Durie, Mason 306, 307 Durkheim, Émile 532

Dwork, Deborah 323 Dyson, Tim 293

early modern medicine (c.1390) death 361 methodological approaches 64–8 Republic of Letters 62 source material 68–70 Eastern Europe 208–18 eugenics 216–17 genetics 213 history of medicine in 213–17 economics 260, 273–4, 303, 377, 378, 382, 439, 442–4 Ecuador 248, 253, 255, 259, 261 Eddy, Mary Baker 587 Edessa 172, 173 Edinburgh: medical training model 227 physiology of ageing 343 EEG (electro-encephalograph) 534 efficiency 102, 104–8 Egypt 24, 26, 179, 183, 563, 582 Ehrenreich, Barbara and English, Deirdre 487–8, 491, 495 Ehrlich, Paul 569 eighteenth century 82–93 children’s admission to hospital 327, 328 colonial medicine 88–9 experimental therapies 90 fertility patterns 377 hospitals 92–3 medical centralization and local diversity 91–2 medicalization of 86–8 menopause 346 onset of old age 340–1 prolongevity 348 sensibilities of death 365 Eksteins, Modris 110 electrical therapies 90, 588 electrophysiological technology 531 Elgood, Cyril 178 Eli Lilly (pharmaceutical company) 400 Elkeles, Barbara 549

index Elkington, Dr J. S. C. 313 Elliott, Rosemary 121 Ellis, Albert 536 Ellis, Havelock 510, 515–16 Ellis, James G. 610 Elton, G. R. 5–6, 7 embryonic stem cell science 554 emotional hyperglycaemia 568 emotions 34, 35, 524, 525, 531 Empedocles 31 empiricism 63, 67, 102, 112, 152, 175, 228, 229, 244, 245, 343, 373, 374, 416, 419 encephalitis 141 encyclopaedism 51, 55, 192, 193 endocrinology 257, 400, 423, 533 end-of-life issues 553–4 Engels, Friedrich 201, 396 English, Peter C. 458 Enlightenment 65, 82–93, 190, 346, 348, 359, 361, 362, 546 environmental issues 122, 230, 233–4, 380, 450–1, 456–60, 462, 494, 533 Epicureans 35 epidemics 200–1, 215, 393, 411, 456 ancient Chinese medicine and 156 in Arabia 176 collective memory of 609, 610 Greek medicine and 31 hospitalization 289 immigration and 233, 245 India 288–90 Latin America 246, 251 public health and 412, 417, 419–20, 423, 424 religious pilgrimages and 289–90 Song period 158–9 syphilis 511 two causes of 180, 186 n.48 typhus 210, see also smallpox epidemiology 12, 121, 128, 143, 374–6, 379–84, 386, 387, 394, 395, 526, 538, 624 chronic disease 236, 293, 394–5, 402, 403, 404, 406 ‘life-style’ factors 460 public health 411, 412, 413, 414, 419–20, 423 surveillance 260



epilepsy 30, 47, 534 epistemology 24, 35, 62, 82, 85, 86, 110, 178, 469, 471, 474–5, 476, 477–9, 562, 579, 582, 585, 586, 590, 603, 605, see also knowledge Epstein, Richard 412 Erasistratus 24, 28, 30 Erasmus of Rotterdam 68 Esquirol, Jean-Etienne 526 ethics, see medical ethics Ethiopia 140 ethnicity 128, 244, 285, 496 ethnography 280, 307, 606 Euclid, Elements 173 eugenics 211, 212, 215, 216–17, 232–5, 249, 304, 311, 322, 378, 417, 421, 530, 550 Euripides 31 European Fertility Project 375 euthanasia 338, 361, 364, 550, 619 evangelicalism 266, 270, 271, 357, 358, 361 Evans, Richard J. 9, 414 Evenden, Doreen 492–3 evil air healing 246 exercise 33, 347, 348 experimental film 619–20 eye problems 52, 342 Eysenck, Hans 535

Fabri de Peiresc, Nicholas-Claude 62 faciomancy 162 faith healing 84, 170, 266, 271 Falun gong movement 163 family planning 120, 231, 379, 494, 496, 516 famine 292, 379, 385–6, 406, 609–10 Faris, Robert 533 Farr, William 201, 382 Fassin, Didier 277–8 fatigue 143, 454 Faulkner, William 1, 13 Fayreford, Thomas 46–6, 54 Fee, Elizabeth 230, 414, 458 Fee, Elizabeth and Fox, Daniel 118–19 Feierman, Steven 275, 276 Felicie, Jacoba (or Jacqueline) 47 Félix, Charles-François 199 femininity 87, 88, 489, 508, 605



index

feminism 7, 214, 324, 420, 485, 487, 488, 489, 503, 505, 512, 517, 519, 605 Ferdinand I, Holy Roman Emperor 66 Fernel, Jean 72 Ferrera, Leonello d’Este, Marquis of 66 fertility 48–9, 200, 269, 374, 375, 376–9, 379, 385, 508 Festle, Mary Jo 601–2 Fett, Sharla 228–9 fevers 43, 89, 156, 161, 171, 176, 395, 396, 487 Ficino, Marsilio 64, 72 Fido, Rebecca and Potts, Maggie 604 Field, Mark G. 210 film: audience issues 627–8, 630 drama 619 experimental film 619–20, 628 health education 620–3, 629 television medical documentaries 624–5, 629 Finland 140, 385 Finlay, Carlos 253 Fioravanti, Leonardo 63 First World War (1914–18) 107, 110, 213, 508 draftees with chronic conditions 402 mass bereavement in 358, 359, 367, 368 psychiatry and 532 venereal disease 513 Fissell, Mary 492 Five Agents schema 155 Fleck, Ludwik 471, 474–8 Flexner, Abraham 230, 586 Flint, Karen 276 Floud, R. S., Wachter, K. W., and Gregory, A. 322 Floyer, Sir John 584 folk medicine 46–7, 49–50, 71, 180, 193 Africa 267–9, 274, 276, 277, 279 corporate medicine and 199 Eastern Europe 214, 215 faith healing 84, 170, 266, 271 herbalism 580 Hippocratic-Galenic influence on 61 humoral theory 181 Latin America 245, 247, 249–50, 251, 257 Western Europe 194, see also alternative medicine

folk memory 609–10 food supply 376–7, 571 foot and mouth disease 571, 599 Ford, John 275 Foreest, Pieter van 63 Forman, Simon 80 n. Foucault, Michel 8, 82, 95 n., 100, 111–12, 244, 293, 421, 424, 528, 538 on architecture 451 on asylums 529 on forming concepts 479 on public health 420, 421, 422 on sexuality and power 211, 504, 505 Fourth Lateran Council (1215) 50 Fox, Daniel M. 125 Fox, Daniel M. and Lawrence, Christopher 618 foxgloves (Digitalis purpura) 199 Framingham Heart Study (1947–50) 236, 404, 422, 459, see also epidemiology France 140, 203 child welfare in 323 contemporary history 118, 122 demography 376 early modern medicine in 66 epidemiology 382 excommunication and burial rites in 358 experimental therapies in 90 geriatric medicine in 344, 345 hospitals in 438 life expectancy in 341 as medical model for Latin America 243–4, 249, 256 mutalism in 434, 435, 441 National Front in 513 population health indicators comparison 444–6 regulation of prostitution in 507 school of ‘historical epistemology’ 477 surgeons in 199 wars of religion (1562–98) 61 welfare system in 429, 430, 432, 437, 441–2, 443, see also Paris Franco-Prussian War (1870–1) 107, 323, 376 Frank, Arthur 405 Frank, Johann Peter 91, 415 Franklin, Benjamin 227

index Frederick, Bronwyn 307 Freedom of Information legislation 123–4, 520 French, Mrs Elizabeth 338–9 French, Roger 545–6 French Revolution 93, 472 Freud, Sigmund 109, 273, 348, 360, 504, 531, 532 Frickel, Scott 460 Frieden, Nancy 210 friendly societies 434 Fritzl, Josef 325 funeral directors 360 Fussell, Paul 110

Galen/Galenism 21, 24, 27, 28, 64, 71, 86, 102, 178, 181, 183, 184, 192, 277, 344, 471 on the ageing process 342, 344, 347 anatomical knowledge 176–7, 187 n.60 animal observation and experiment 563 commentaries on 175 discrepancies 63, 65 and the divine 23–4 early modern medicine 71 eighteenth century 83 in Latin America 246, 250 magic in works by 176, 180 medieval medicine 41, 43, 44, 51, 55, 61 on physicians 179 psychological health 35 quality of life 348 texts 27, 28, 68 translations of 173, 174, 194 Western European medicine 194, 198, 277, 472, see also humoral theory Galenico-Islamic medicine 171–2, 181, 183, 184 Galileo Galilei 62, 473 Galison, Peter 479 Galton, Francis 216 Galvani, Luigi 90 Gama, Vasco da 285 Gantt, Horsley 210 Garrett, E., et al 375, 378 Garrett, Laurie 422 Garrido, Philip 325 Garton, Stephen 313 gastric ulcers 533



Gaulle, Charles de 441 Gawin, Magdalena 216 gay and lesbian studies 504 gay liberation 503 Gazdag, Gábor 216 Gelfand, Michael 267 gender 27, 68, 191, 212, 485–9, 496 eighteenth-century naturalization of 87–8 industrial health 454–5 mental health 491 reproduction and 211, 214 sex education and 517 sexual ‘double standard’ 506, 507, 510, 512 television and film 619 General Medical Council 547 genetics 71, 121, 216, 235, 551–2 Soviet Union 212–13 United States 234–5 Genoa 196 Georgiev, Mincho 214 Gerard of Cremona 194 geriatrics 344–5, 347, 350, 403, 404, 415, see also old age Germany 329, 414 anti-vivisection movement in 549 bacteriology 249 epidemiology 382 eugenics movement in 212 geriatric medicine in 344, 345 health insurance in 429, 430 homosexuality in 510 human experimentation in 549–51 industrial health in 454 life expectancy in 341 medical ethics in 546, 555 medical profession in 203 population health indicators comparison 444–6 public health in 419 punishment of professional misconduct 547–8 Salk polio vaccine 122 training American physicians in 229 use of ‘psychology’ 527 welfare system in 432, 436, 438, 440, 441, 443 workers’ sickness funds in 434



index

germ theory of disease 202, 230, 233, 413, 461, 495, 569, 602 gerontology 325, 345, 347, see also ageing process Gevitz, Norman 587, 588 Geyer-Kordesch, Johanna 494 al-Ghazzāli, Mohammad 173, 182 ghosts 359 Gieryn, Tom 236 Gijswijt-Hofstra, Marijke and Marland, Hilary 323, 330, 331–2, 588 Gillespie, James 312 Gisborne, Revd Thomas 544 Gittins, Diana 121, 604 Glasser, Brian 619 Gleadle, Kathryn 490–1 globalization 22, 56, 89, 122, 145, 451 global smallpox eradication programme 135–45 glycogen synthesis 567–8 Goa 285, 583 gold 197 Goldman, Wendy 211 Goldstein, Kurt 534 Gondishâpûr tradition 172 gonorrhoea 549, 568, 622 Good, Charles 271, 275 Gorer, Geoffrey 359, 367 Gorgas, William 253, 255 Gorsky, Martin 11–12, 122 gout 40, 87, 395, 583–4 government(s) 136 alchemists 157 archive availability 124 centralized management of disease 91–2, 104 contemporary history 118 funding 231–2, 295 global smallpox eradication programme 137–45 health legislation 250 ideology of efficiency 106 medicalization 200–5 ‘revolution in’ 417–18, see also public health; national health insurance Gowing, Laura 486 Gradskova, Julia 212

Graeco-Roman medicine 10, 21–36, 181, 192 ethics 545 influence on early modern medicine 61, 71 Islamic medicine and 170, 183, 184 medical conceptions of ageing 342 pluralism in 29–30 rival perspectives on competence 30–1 veterinary medicine 562, 563 Graham, James 90 Graham, Loren R. 210, 212 Gramsci, Antonio 288, 293 Great Finnish Famine (1860s) 385 Great Ormond Street Hospital, London 322 Greece 190, 386, 582, see also Graeco–Roman medicine Greek tragedy 31 ‘green sickness’ 486 Gregg, Alan 230 Gregory, John 544 Grene, Marjorie 473 Griesinger, Wilhelm 526, 530 Groddeck, George 533 Grotjahn, Alfred 414 guaiac wood 197 Gueraula de Codines 43, 44, 47 Guest, Simon 602 Guevara, Ernesto ‘Che’ 259 Guha, Sumit 293 guilds 64, 85, 191, 195, 197, 227 Gunning, Tom 628 gun shot wounds 178, 197 Gurjeva, Lyubov 495 Gurney, Edmund 530 Gutas, Dimitri 173 gynaecology 46, 47, 48, 484, 485, 488, 489–90

Habsburg Empire 85–6, 91, 214, 416 Hacking, Ian 525 hadiths 181, 182 haemophilia 599 haemorrhoids 46, 161 Haggett, Ali 602 Hahnemann, Samuel 585, 586, 587 hair loss 46 Haitians 233

index Ḥâji Khalifa 181 Hales, Stephen 88 Haller, John 587, 589 Halliday, James Lorimer 6 hallucinations 157 Hamburg 201–2 Hamilton, Max 535 Hammonds, E. M. 418, 419 Han dynasty 150, 151, 154, 156 Haraway, Donna 573 Hardy, Anne 418 Harley, David 486, 538 Harlib, Samuel 62 Harrân tradition 172 Harrington, Anne 538 Harris, Bernard 322, 380 Harris, Ruth 277 Harrison, Barbara 495 Harvard Medical School 229, 553 Harvey, David 457 Harvey, William 64, 65, 102, 110, 198, 342, 471, 564, 619 Haslam, John 526 Haupt, Heinz-Gerhard and Kocka, Jürgen 555 Hawthorne experiment (1920s) 454 Hayes, Sarah 331 Hayward, Rhodri 8, 10 headaches/headache remedies 46, 52, 170, 181 head lice 326 health: advice literature 86, 488, 494, 495–6 climate and 31, 88–9 divinatory calculations and 152 economics 231 education 215, 303, 422–3, 424, 620–3, 629 environmental factors and 31, 34 Graeco-Roman medicine and 26, 27 morality and 87, 89 normativity 478 in old age 347–8 preservation of 179, 180 virtue and 156, 157, 161 Health and History (journal) 304, 305, 306–7, 310 Health Education Council 623 health impact assessment (HIA) 12



health insurance 202, 231–2, 387, 404, 429, 431, 436, 546 heart disease 121, 342–4, 384, 394, 402, see also cardiology heart transplants 553 heat treatment 154 heavy metal lead 458 Helsinki Declaration (1964) 550–1 Henderson, D. A. 139, 140 Hendrick, Harry 322, 330 henna 181 Hennessy, Peter 118, 123 Henry IV, King 66 Heraclides 28 herbalism 84, 246, 250, 279, 491, 580, 586 heredity 213, 233, 234, 472 Hering, Sabine 215 hernias 85, 161 Herophilus 24, 28, 563 Hess, Ann 493 Hessen, Boris 469 heterodox medicine, see alternative medicine; folk medicine hexamethonium 401 Higgs, Eddy 376 Hill, John 348 Hill Burton Act (1946) 232 Hindu medicine 270–1 Hindu pilgrimages 289, 290 Hippocrates 21, 22, 27–30, 44, 61, 65, 71, 86, 171, 175, 181, 184, 268, 414, 528, 563 on ageing 342 Airs, Waters and Places 450, 451, 456, 459, 462–3, 528 description of syphilis symptoms 511 on melancholia 525 on the menopause 346 translations of 174 Western European medicine and 190 Hippocratic Corpus 28, 30, 31, 32, 36 n., 41, 80 n., 173, 471, 545, 562 Hippocratic Oath 21, 545 hip replacements 402 History and Policy network 11 HIV (immunodeficiency virus) 117, 118–19, 120, 123, 266, 272, 273, 274, 277–8, 512, 514, 603, see also AIDS



index

Hobsbawm, Eric 125 Hoffmann, Friedrich 546 holism 592 Holmes, J. B. 622 Holocaust 209, 212 holy men 285 home pregnancy tests 601 Homer 340 homoeopathy 249, 250, 546, 578, 581, 585, 586, 588, 589, 590, 592 homoeostasis 534 homosexuality 503, 504, 510–11, 513–14, 515, 519, 537, 602, 604 Honduras 261 hookworm 228, 230, 252, 254–5, 312 hormones 400, 569 Horney, Karen 532 Horrox, Rosemary 360 horses 566, 568 hospices 363–5 hospital(s) 191, 199, 472 administration 104–5 American 232 animal testing in 570 architecture 102 Australian 305 charity 246, 249, 252, 256, 435 children’s 321, 322 children’s admission to 327–9 colonial 285, 583 concentration of expertise in 438 Crimean War 201 death in 359, 364, 367 eighteenth-century 92–3 geriatric care in 345 history of 54–5, 305 Indian 294–5 industrialists and 105–6 insurance 232 Latin American 246, 249, 252, 258, 259 lying-in 294, 493 mental 534–5 Newcastle study of 122 New Zealand 312 poor law 362, 402, 404 regulations 544 scientific management of 107

scientific medicine 203 veterinary 565, 566 voluntary 363 women-run 490 women’s 484 Houblonnière, Ranulphe de la 50 Houlbrooke, Ralph 360 household medicine 71, 85 housing 234, 415, 419, 623 Houssay, Bernardo 257 Howard, John 420 Hua Tuo 155 Hueper, Wilhelm 460 Hughes, H. L. Glyn 364 Huihui yaofang 161 Huisman, Frank and Warner, John Harley 2, 3 human dissection 28, 41, 65–8, 154–5, 176–8, 198, 235, 362–3, 398, 563, 564, 584 human exceptionalism 561, 563, 572 human experimentation 545, 548–52, 609 Tuskegee Syphilis Experiment 120, 235, 414, 421, 548, 551, 609 humanism 40, 61, 102 Human Organ Transplants Act (1989) 553 Human Tissue Acts (1961 and 2004) 553 Hume, David 544 humoral theory 86, 88, 91, 175, 176, 180, 268, 285, 565, 583, 584 animals and 564–5 folk medicine and 181 Graeco-Roman medicine 29–30 Islam and 171–2, 176 medieval medicine and 30, 41, 44, 46 old age and 342, 343 Humphrey, Kim 306 Humphreys, Clare 364 Humphreys, Margaret 228 Hunayn ibn Ishâq 171, 173–4, 175 Hungary 209, 214, 215, 216 Hunt, Nancy Rose 275, 277 Hunter, Kathryn Montgomery 601 Hunter, William and John 564 Hurley, Andrew 457 Hutchinson, John F. 4–5, 6, 8, 9, 210 hydropathy 490, 590 hydrostatics 90 hygiene 91, 92, 152, 179, 182, 215, 290, 472, 494

index advice 423 Aztecs 247 child 330 and disease 233 disposal of the dead 366–7 Eastern Europe 213, 214, 215 eighteenth-century 87 germ theory and 202 health education films 621 home 495, 602 institutionalization of 248 in Latin America 250 mental 330 midwives and 487 in pre-Columbian societies 245 racial 311–12 in Russia 210, 211 statistical studies on 201 Hynes, Samuel 110 hyperactivity disorder 331 hypertension 384, 401, 402 hypnosis 528, 530 hypochondria 88, 490 hysteria 491–2, 507, 531

Iarskaia-Smirnova, Elena 212 iatrochemistry 62, 90, 197–8, 472 iatromechanism 62, 63, 90, 472 Ibn Abi Ṣādeq Neishaburi 175 Ibn abi Usaybi‘a 177 Ibn al Qifti 180, 187 n.64 Ibn Elyās 177 Ibn Kâshef, Mirzâ Qâzi 175 Ibn Māsawayh, Yuhanna 177 Ibn Nafis 177–8, 187 n.60 Ibn Qayyim al-Jawziyya 181 Ibn Riḍwān 171, 175, 179 Ibn Rushd (Averroes) 61, 174 Ibn Sina (Avicenna) 41, 44, 55, 61, 171, 174, 177, 184, 194, 471 Iceland 551–2 Ignatieff, Michael 420 IHB (International Health Board) 254, 255–6 Illich, Ivan 82, 394 illness 25, 172, 405, 527



Daoist view of 157 definition 393 oral testimonies of 602, 603 IMF (International Monetary Fund) 260 Immergut, Ellen 433 immigration 200, 377, 383–4 AIDS and 513 Australia 309–12 and epidemics 233 Latin America 243, see also population movement immortality elixirs 157 immune system 513–14 imperialism 190, 213, 243, 244, 247, 252, 430 impotence 509, 510, 513 incantation 156, 158, 176 incurable illness, see chronic illness India 160, 169, 171, 183, 270–1, 276, 277, 285–6, 582, 583 famine (1876–9) 385 global smallpox eradication programme in 137, 139, 140, 141, 142, 143 homosexuality in 519 medical institutions in 293–5 sanitary reform in 290–3 study of epidemics in 288–90 Western and local medical traditions in 286–8 individuality 377, 530–1, 533 industrial health, see occupational health industrialization 100, 107, 162, 200, 261, 343, 382, 431, 452, 569 Industrial Revolution 417, 434 infant food industry 495 infant health 313, 324 infant mortality 215, 247, 321, 323, 355, 375, 383, 385, 444, 508 infectious diseases 12, 71, 161, 203, 215, 229, 230 antibiotic resistance 380 attenuation over time 326, 381, 382 childhood 357, 383, 385 diagnosing 570 famines and 386 Latin America 250–1, 261 pre-Columbian societies and 245, see also epidemics; public health



index

infertility 48–9, 519, see also fertility infirmaries 158, 193, 328, 544, 553, see also hospitals influenza 226, 374, 420 pandemic (1918) 303, 385, 610 inoculation 83, 91, 108, 199, 294, 360, 545, 568 Inquisition 63 insanity 32, 121, 491, 507, 514, 526, 527, 528–9, 530 Institute of Contemporary British History 118 institutionalization of medicine 3–4, 9–10, 25, 62, 64, 84, 191, 248–52, 273, 433, 472 insulin 400–1, 569 International Institute for the Protection of Childhood 258 International Sanitary Conference, Constantinople (1866) 290 invalidism 488, 492 invocation 170, 180, 269 Iran 172, 183 Iraq 139, 172, 179, 582 Ireland 602 Irish famine (1740–1) 385, 386, 609–10 Irish migrants 233 Isaac, Jacob 338 Isidore, Archbishop of Seville 193 Isis (journal of the history of science) 470 Islam 172–4, 190, 270, 289–90 Islamic medicine 55, 169, 170, 268 anatomical knowledge and 177–8 Greek science and 172–4, 181–2 in India 285 modern period 182–3 state sponsorship and 179, 182–3 translations of Graeco-Roman texts 172–3, 177–8 Islets of Langerhans 400 Italy 60, 66, 193, 345 IVF (in vitro fertilization) 554

Jackson, Mark 330–1, 374, 461, 469 Jalland, Pat 356, 361 James I, King 66 Janet, Pierre 530 Janzen, John M. 268, 275, 276 Japan 139, 156, 160, 161, 162, 190, 383, 435, 583, 584

biological warfare research 551 national health insurance 430, 436, 438, 441 population health indicators comparison 444–6 welfare system 443 Jaspers, Karl 533 Jeffery, Roger 291 Jenner, Edward 162, 199, 248, 413, 566–7 Jesuits 161, 247, 583, 590 Jewish-Americans 234 Jews 61, 169, 209, 212 doctors 45, 48, 49 migrants 233 Jewson, N. 627 Jin dynasty 159 jinn, concept of 170, 176 Johan, Béla 214, 215 John Hopkins School of Medicine 229, 230 Johnson, Niall 610 Johnson, Virginia 515 Johnston, Ronald and McIvor, Arthur J. 453, 455 Jones, James 235 Jones, Robert 105, 106, 108 Jonsen, Albert 552 Jordanova, Ludmilla 7, 217, 486, 618 Jorjâni, Esmâ‘îl 180–1 Joseph II, Emperor 85–6 Joyce, Patrick 365 Judaism 170 Jung, Carl 532 Jupp, Peter 368 Justi, Heinrich Gottlob von 91 juvenile delinquency 324, 331

Kaempfer, Engelbert 584 Kaiser Permanente 232 Kakar, Sanjiv 598 Karpf, Anne 618 Kasson, John 455 Kawachi, Ichiro 412 Kay, Lily 234 Kellehear, Alan 358–9, 368 Kennedy, President J. F. 6 Kenya 140, 278 Ker, Patrick 343

index Kerbolt, László 215 Khen, Yulia V. 212 kidney dialysis 552, 626 kidneys 170, 553 King, Helen 486 King, Sir Frederic Truby 313, 495 King-Brown, W. W. 621 Kingsbury, John A. 210 Kinsey, Alfred 509, 515, 516 Kircher, Athanasius 62 Klein, Ira 293 Klein, Rudolf 124–5 Kleinman, Arthur 393, 405 Klepp, Susan 377 knowledge 178 attempted summary of 193 cultural exchange of 582–5 disciplinary divides of 9, 479–80 dissemination of 159, 160 early modern medicine and 81 encyclopaedism 51, 55, 192, 193 Fleck’s theory of 474–7 Ghazzāli on 182 power and 112 transfer 211, 212, 312, see also epistemology Koch, Robert 202, 401, 413, 414, 419, 420, 473, 568 Koran 170, 173, 174, 178, see also Islam Korea 160 Koyré, Alexandre 473 Krafft-Ebing, Richard von 510, 515, 516 Kraut, Alan 233 Krementsov, Nikolai 212 Kruif, Paule de 413, 414 Kübler-Ross, Elisabeth 360 Kühn, Karl Gottlob 21 Kuhn, Thomas S. 471, 473–4, 475, 476, 479 Kumar, Anil 291 Kunitz, Stephen 307–8 Kuriyama, Shigehisa 162, 163

LaBerge, Ann and Coleman, William 416 laboratories 103, 191, 200, 202, 203, 399, 438, 472, 566 animal 567–70, 571 industrialization of 569



medical films 625, 627 psychological 531 training 229 labour relations 417 Laennec, René Théophile Hyacinthe 398 Laing, R. D. 538 La Mettrie, Julien Offray de 93 Landecker, Hannah 620 Lange, Raeburn 306, 307 Lapidus, Gail 211 Laqueur, Thomas 366, 489, 505 Lashley, Karl 534 Laslett, Peter 349 Last, Murray 275 Latin America 243–62, 582 abortion regulation in 519 Cold War period in 257–60 colonial medicine in 245–8 French medical training model in 243–4, 249, 256 infant mortality rate 375 nineteenth-century institutional growth in 248–52 pre-Columbian health conditions 245 radical physicians in 258, 259–60 Rockefeller Foundation in 254–6, 257, 421 syphilis epidemic in 511 tropical medicine in 252–4 Yellow Fever Commission in 255 Latin American School of Medicine, Cuba 261 Latin America Social Medicine Association (ALAMES) 260 Latour, Bruno 474 Latvia 215 Lawrence, Chris 619 lead 157 lead poisoning 458 League of Nations 214 Leake, Chauncey D. 544 Leavitt, Judith 601 Lederer, Susan 235, 550, 618 leeches 566 Leibniz, Gottfried Wilhelm 62 Leiden, University of 66, 92, 199, 472 Leipzig 67 psychological laboratories 531 Lemba cult 266, 268, 276



index

Lémery, Nicholas 198 Lenin, Vladimir 210, 415 Leon, Ponce de 348 leprosaria 246 leprosy 279, 293–4, 310, 311, 568, 598 lesbianism 504, 510, 608 lethal dose test 570 leucocytosis 533 leucotomy 534 Leunig, T. and Voth, H. J. 322 Levene, Alysa 322 Levene, Alysa, Reinarz, J., and Williams, A. 328 Lewis, Jane 121 Lewis, Milton 312, 313 Lewis, Sinclair 414 Leyden 92 liberalism 417–18, 434, 435 Liceaga, Dr. Eduardo 250–1 life expectancy 12, 259, 340–1, 345, 379, 381–2, 444, 470 lifestyle 26, 33, 62 disease prevention 86–7 disorderly 161 health risks and 421, 422–3, 424, 444, 446, 460, 513–14, 519 public health and 121 life support machines 356 Lima Convention (1888) 253 Linacre, Thomas 63 Lind, James 89 Linden, David 545 Lindner, U. and Blume, S. 122 Lister, Martin 62 literacy 61, 377 lithium 536 Littré, Emile 21 liver 170, 567–8 liver transplants 553 Livingstone, Julie 278, 603 Lloyd George, David 433 Lo, Vivienne 279 Loane, M. E. 361–2 Locke, John 93, 527 Lohmann, Theodor 436 Lomax, Elizabeth 322 Long, Vicky and Marland, Hilary 495

longevity 156, 157, 340–2, 350, 385, 387, 446 Loudon, Irvine 321, 493 Loughlin, Kelly 625, 626 Louis XII, King of France 66 Louis XIV, King of France 199 Louis XVI, King of France 86 Lovelace, Ada, Lady 367 Low, Rachel 619 Lowe, Rodney 117 Lower, Richard 572 Lρkke, Anne 487 Luckin, Bill 418, 458 Lu Gwei-djen and Needham, Joseph 590 Lumière Brothers 620 lung cancer 402 lung transplants 553, 601 Lupton, Deborah and Peterson, Alan 423–4 Lysenko, Trofim 212–13

McCalman, Janet 305, 307, 314 McCarthy, Angela 314 McClive, Cathy 486 McCulloch, Jock 279 McCullough, Laurence 543 Macintyre, John 620 McIvor, Arthur and Johnston, Ronald 603 McKeown, Thomas 3, 4, 5, 6, 8, 9, 12, 373, 380–2, 446 MacLeod, Roy 304 McVaugh, Michael 43 magic 27, 30, 42, 47, 84, 175, 246, 249, 585, 588 Islamic medicine and 170, 176, 181 medieval medicine and 48–9 pre-Columbian societies and 245 sympathetic 176, see also witchcraft magnetism 90, 585 Magnuson, Paul 404 mai channels 153, 154, 163 Maienschein, Jane 554 Maimonides 179 al-Majusi 177, 184 Makgill, Dr R. H. 313 malaria 54, 122, 228, 235, 247, 252, 254, 258, 272, 279, 288, 292–3, 295, 420, 454, 460, 461

index Malawi 271, 273, 275 Malaysia 454 malnutrition 215, 420 Malowany, Maureen 276 Malthus, Thomas 91, 376–7, 385 Manchester 487 Manchester Royal Infirmary 328, 544 Manderson, Lenore 312 Mandeville, Bernard 93 Maoris 306, 311 Marey, Étienne-Jules 619, 620 Markel, Howard 233, 234, 374 Marks, L. 122 Marks, Shula 279 Marseilles 196 Marsh, Rosalind 211 Marshall, T. H. 432 Marshall Plan 439 Martin, Lillien J. 345 Marwick, Arthur 6–7 Marx, Karl 109, 413, 420 Marxism 244, 431 masculinity 87–8, 275, 455, 506, 509, 520, 603 Mason, Dr J. M. 313 massage 105, 154, 247 mass bereavement 358, 359, 367, 368 Masters, William 515, 516 masturbation 87–8, 330, 348, 509, 510, 520 materialism 33–5, 197, 198–200, 244, 277, 564, 579 maternalism 324, 327–8 maternity hospitals 294 Matthews, Shannon 324–5 Maudsley Personality Inventory 535 Maximilian I 66 Maya 245, 250 Mayer, Alexandre 507 Mayerne, Theodore de 66 Mayo, William 105, 106 Mayo Clinic, Minnesota 104, 105 Mbeki, President Thabo 120, 278 measles 226, 245, 326 Mecca 289, 290 media 69, 70, 234–5, 494, 496, 517, 553, 609, 618, see also film; television Medical Act (1858) 203 medical digests 175



medical entrepreneurship 85–6 medical ethics 125, 534–55, 563, 569–70, 606–8, 626 medical geography 243, 451 Medical History (journal) 119 medical innovation 85, 121, 195, 197–200, 360, 402, 414, 438, 569 medical instruments 27, 53, 62, 63, 70, 178–9, 398 medicalization 86–8, 322, 492 of childbirth 605 of children 322 of contraception 518 of death 360, 363, 367, 368 of homosexuality 510 of the nation-state 200–4 of old age 344 of the standards of normality 331 of women’s health 495 medical journals 214, 221 n.33, 249, 276–7, 345, 489 medical literature 27, 28, 193, 473, 526 ancient Chinese 56, 153–6, 159 Arabic and Syric translations of 172–4, 176–7 Buddhist 158 on children’s health 327 commentaries on 174–5 court medicine 66 cross-cultural transmission of 160 early modern 68–70, 71, 72 Eastern European 209 eighteenth-century 86 folk 182 Galenico-Islamic 171 Graeco-Roman 22–3, 26, 27–8, 40, 41, 60, 61, 68, 194 Hippocratic Corpus 28, 30, 31, 32 Islamic 171, 174–5, 179–81 on medical ethics 544 medieval 46, 51–3 on old age 343 print culture and 62 on prolongevity 348–9 prophetic 181–2 vernacularization of 44–5, 48, 53, 60–1, 65 Medical Research Council 123, 401, 404



index

medical statistics 375–6, 419, 424 medical training 41, 84–5, 227, 229 American 227, 229 in Britain 313 colonial India 287 controlling standards of 547 Eastern Europe 213–14 Edinburgh model of 227 eighteenth-century 83, 92 in ethics 545 French model of 243–4, 249, 256 Latin America 256, 260, 261 Mexico 249 philanthropic foundations 230 Song dynasty 158, 159 Soviet Union and 259 veterinary 565–6 western medicine in China 162, see also universities Medicare/Medicaid 430, 441, 442, 443 medicinal plants 67, 89, 152, 153, 158, 170, 193, 194, 197, 199, 247, 285, 288, 491, 583 medicine 191 animal and human 561–73 cross-cultural 66, 580–1, 582–7, 590, 591, 592 definitions 171 institutionalization of 3–4, 9–10, 25, 62, 84, 191, 248–52, 273, 433, 472 interspecies interaction 562, 565, 566, 567, 568, 569, 570, 571, 572–3 media and 618 regulation of 84, 101, 107, 195–6, 553 scientific revolution and 471–4 use of cine camera in 619–20 medieval medicine 40–56 Chinese 156 Christianity and 49–50 death and 360 early modern medicine and 60, 61, 65 historiography of 43–5, 53 humoral theory and 30, 41, 44, 46 magic and 48–9 male and female practitioners of 45–8, 51, 54 menopause and 346 scholasticism 40–7, 51, 55

vulture medicine 51–3 meditation 156, 158 mediums 156, 269 Meiji Restoration (1868) 162 Melegh, Attila 216 Melling, Joseph and Bufton, Mark W. 453 Mellor, Philip 368 Melosi, Martin V. 457, 458 menopause 340, 346–7, 488 menstruation 488 mental health 273, 323, 402, 532, 534–5 charity and 435 children’s 330–1 contemporary history of 121 eugenics and 216 Graeco-Roman medicine and 26, 31–3, 32–4 ‘myth’ of mental illness 538 oral testimony of 604, 605, 608 women and 491, 494, 602 Mercuriale, Girolamo 72 mercury 157, 197 Mering, Joseph von 400 Mersenne, Marin 62 Mesmer, Dr. Franz Anton 90, 527, 585, 587 mesmerism 527–8, 531, 581, 588 mesothelioma 603 Messina 67 Metchnikoff, Elie 348 Mexico 243, 246–7, 249, 250–1, 255, 256, 258, 259, 260, 261, 454 Mexico City 247 Meyer, Adolf 533 miasma theory 88–9, 366, 461 Middle Ages 191 middle class 65, 233, 256, 304, 305, 330, 384, 433, 437, 443, 492, 508 midwives 62, 228, 484, 492–3 abortion and 518 male 85, 492–3, 495 maternal death and 493 Mexican 246–7, 249 obstetricians and 601 public health and 487 witchcraft and 486, 487 migraine 46, 52 Milingo, Archbishop 271

index Milton, James 363 mind sciences 524–7, 537–8 Minkowski, Oskar 400 Minois, George 349, 350 miracle healers 30, 349 miracles 177, 355 Mirceva, Gergana 216 Mirsky, Mark B. 212 missionaries/missionary medicine 89, 161, 246, 259, 271, 272, 275–6, 286, 295, 296, 583 Mitchinson, Wendy 607–8 Mitman, Gregg 234, 461 modernity 100–14, 355, 377, 394, 420, 555, 561, 623 modernization 101, 183, 255, 256, 291, 374, 382, 431 Mohammad, Prophet 170, 178 Mohammad Ali, ruler of Egypt 183 Mohan, J. 122 Moldovan, Iuliu 214 molecular biology 121, 234 Molière 40 Molina, Natalia 458 Moll, Albert 545 monasticism 51, 52, 158, 193–4 Mongolia 56, 159–60, 161 Moniz, Egas 534 Monroe Doctrine (1823) 254 Montague, Lady Mary Wortley 199 Montefeltro, Federico da 66 Montpellier, University of 66, 195, 199 Mooney, Graham 418 morality 355, 517, 519, 544 health and 87, 89 health education films and 622 self-restraint 34–5 statistics 250 Victorian 506 moral panics 278 moral therapy 527, 528–9, 531 Morantz, Regina M. 489 Morantz, Regina M. and Zschoche, Sue 490 morbidity 12, 293, 322, 323, 376, 377, 379, 387, 402, 424, 434, 439, 513, 600 Moreau du Tours 530 Morel, Benedict-Augustin 526, 530



Morris, Jerry 125, 404 mortality rates 12, 200, 201, 374, 403, 420, 470 amenable 446 decline 382 early-life risks and 384–5 epidemics 196, 288 epidemiological transition 379–81 European conquest of Meso-America 245 famine and 385–6 fertility and 385 infant 215, 247, 321, 323, 355, 375, 383, 444, 508 influenza 374 morbidity and 12, 293, 322, 323, 376, 377, 379, 387, 402, 424, 434, 439, 513, 600 population and 37 mortality studies 83, 90, 93, 293 Mortimer, Ian 360–1 Moscucci, Ornella 489–90 Mosley, Stephen 458 mosquito control 253, 255, 292 motherhood 485, 488, 491, 508, 605 Mottram, Joan 487 moxibustion 152–3, 154, 583, 584 Mozambique 143 Mughal Empire 285 multiculturalism 362 Munk, William 361 Murphy, Michelle 454 Murray, John F. 473 muscular atrophy 343 music 54, 62, 68, 110, 269 Musil, Robert 112 mutualism 434–5, 436, 437 Myers, Frederic 530

Napier, Richard 80 n. Napoleonic Wars 107 Nascher, Ignatz 344–5 Nash, Linda 460, 461 national efficiency 304, 322, 324 national health: debilitated state of army recruits 402, 436 maternal and foetal 494–5 wartime 323



index

national health insurance 106, 202, 203, 231–2, 387, 404, 429, 431, 432, 436–8, 442, 444, 532, 546 National Health Service Act (1946) 231 national identity 183, 309–12 National Insurance Act (1911) 410 nationalism 110, 214, 215, 228, 287, 289, 302, 303, 309, 311, 610 Native Americans 225, 226 Native Medical Institution, Calcutta 287 natural history 62, 70 natural laws 87, 93 naturopathy 578, 581, 588 Nazism 438, 440, 510, 548, 550, 619 Needham, Joseph 150, 155 Neisser, Albert 549 neoliberalism 274 nervous system 28, 102–3, 199 Nestor, King of Pylos 340 Netherlands 118, 120, 121, 140, 323, 330, 331, 583, 584 ‘Hungerwinter’ (1944–5) 386 life expectancy in 341 Salk polio vaccine 122 Nethersole, Olga 622 Neumann, Sebastian 416 neurasthenia 102–3, 114, 491–2, 532 neurology 108 Newman, George 621 Newsholme, Arthur 210 New York 620 degeneracy and disease 233 medical ethics 546 New Zealand 122, 302–8, 311–14, 401, 430 ngoma healing 268, 269, 276 NGOs (non-governmental organizations) 124, 136 Ngubane, Harriet 275 NHS (National Health Service) 364, 402, 404, 432, 439–40, 442, 444, 446, 601, 602, 624 documentaries 625, 629 ethical review 125 history of 118, 122 oral histories of 124–5, 609 ‘Research Ethics Committees’ 606 Nicaragua 260

Nicholls, Phillip 587–8 Nicolò III d’Este 66 Nigeria 273 Nightingale, Florence 201, 361 nineteenth century: alternative medicine 584, 585, 586, 587, 588, 589, 591 animals 567, 570 children’s medicine 322, 325, 326, 330 Chinese medicine 161 chronic illness 393, 395–8, 401, 406 codes of medical ethics 546 colonial medicine 271, 273, 276, 287, 295, 303, 311 consumption 395, 405 death 355, 356, 357, 358, 360, 361, 362, 363, 365, 367, 368 degeneration 102 demography 375–6, 382, 383 environmental issues 451, 454, 459, 461, 472 ‘epidemiological transition’ 373 experimental film 619–20 Hippocratic-Galenic tradition 21, 44 Islamic medicine 176, 183 Latin America 243, 246, 248–51, 253, 256 life expectancy 382 medical ethics 544, 546, 547, 548 medicalization 200–4 menopause 346 mental health 526, 529, 531 old age 343–4 Parisian clinical medicine 93 political economy 430, 433, 434, 435 public health 91, 412, 414, 417, 421, 422, 423, 424 Russian medicine 212 sexuality and health 503–4, 506–8, 509, 510, 511–12, 514, 516, 520 suburbanization 384 Weberian modernity 103–5, 114 women’s health 485–6, 489, 490, 491, 492, 493, 494, 496 Nixon, President Richard 443, 591 normativity 478–9 Norway 121, 203, 429 novels 72, 396, 531, 618 Numbers, Ronald 227, 587

index numerology 24, 153–4 Nuremberg Code 550, 551 Nuremberg Doctors’ Trial (1946–47) 549, 550 nurses/nursing 85, 201, 203, 214 Africa 273 colonial mission 275 the dying 361–2 oral histories of 600 public health 415 shift in perception of 487 nutrition 415, 623 Nutton, Vivian 545

Oakley, Ann 495 Obama, President Barack 232, 444 obesity 111, 121, 406, 424 obstetrics 212, 484, 486, 488, 489, 600, 601 occupational hazards 452–5, 454, 455, 460 occupational health 91, 122, 272, 293, 452–5, 460, 534, 603 Oedipus 31 Offer, A. 121 Offray de la Mettrie, Julien 199 Ó Grása, Cormac 385–6 Ogun cult 266, 268, 269 old age 10, 338–50, 340–5, 402, 496, see also geriatrics Omayyads 179 Omran, Abdel 379–84, 406 onanism 87–8, 510, see also masturbation operant conditioning 536 ophthalmology 171, 175 opium 40, 360 optics 473 optometry 228 oral contraception 120, 121, 122, 517–18, 519 oral history 124, 128, 170, 194, 214, 280, 285, 496, 598–611 collective memories 608–10 contraception 378 ethics and date protection 606–8 medical practitioners 600–1 patients 601–6 organ donation 552, 553 organ transplantation 553, 572, 601



Oribasius 174, 175 Orme, Nicholas 325 orthopaedics 108 Osler, Sir William 570 Osler Club of London 4 osteoarchaeology 70 osteopathy 228, 578, 587, 588 osteoporosis 344, 347 Ostherr, Kirsten 619 Ott, Katherine 236 Ottaway, Susannah 10 Ottoman Empire 91 ovariotomy 488, 507 Oxford University 46

Packard, Randall M. 275, 279, 454, 461, 604 Padua, University of 66, 67, 198, 471 paediatrics 321, 325, 327, 331, see also children paganism 169, 173, 178, 193, 270 pain 24, 25, 34, 35, 62, 153, 154, 163, 181, 342, 567 pain relief 31, 192, 361, 364, 397, 405, 605 Pakistan, smallpox eradication programme 137, 139 palaeopathology 53–4 Palladino, Paolo 8 palliative care 364, 405 Palló, Gábor 215 palsy 342 Panama 248, 253 Panama Canal 253–4, 255 pandemics 196, 290, 374, 379, 380, 385, 406, 562 Pappworth, Maurice 551 Paracelsus/Paracelsianism 41, 63, 64, 66, 197, 198, 342, 349 paradigmatic science 471, 473, 474, 475, 476, 479 Paraguay 257, 260, 261 paralysis 90 Paré, Ambroise 197 Paris 66 Collège de Pharmacie 84 eighteenth-century clinical care 92–3 licensed medical teaching 195 surgeons 199 universities 196, see also France



index

Parker, Andrew 310 Parkes, Colin Murray 360 Parkinson’s disease 620 Parle, Julie 273 Parry, Suzanne 305, 308, 309, 310 PASB (Pan American Sanitary Bureau) 254, 258 Pasteur, Louis 202, 250, 413–14, 473, 474, 568 patent medicines 84, 86, 348, 546 pathogens 161, 275, 456–9, 550 pathology 111, 202 patients 191 child 326–9, 333 declaration of rights 552 ‘disease education’ 626 experimentation on 548–52 female 488–90 medical ethics and 548 oral testimonies of 601–6 ritualistic forms of speech or writing and 269–70 Roy Porter on 275 subjects of film 620, 628 in television documentaries 626–7 women 488–90 patriarchy 327, 485, 486, 489, 490, 491, 503 Patrice Lumumba Friendship University 259 patronage 61, 84, 106, 157, 169, 256 Paul, Diane 234 Paul of Aegina 61, 177 Paul of Middelburg 66 Pavia, University of 92, 195 Pavlov, Ivan Petrovitch 534, 536 Pearson, Dr Alexander 162 Pearson, Karl 216 Peitzman, Steven 399 Pelling, Margaret 328, 493 Pellow, David Naguib 457 Pemberton, Stephen 234 penicillin 102, 229, 513 pensions crisis 350 People’s League of Health 622 pepper 193 Percival, Thomas 543, 547 Pernick, Martin 619 Persia 160, 169, 170, 173, 270 persistent vegetative state 554

personality tests 535–6 Peru 60, 245, 248, 250, 251, 253, 255, 256, 259 pesticides 258, 460, 462 Petermann, Lisa 327 Peter of Spain 49 Petrarch 65 Pettenkoffer, Max Joseph von 202, 419 Peucer, Caspar 66 pharmaceutical industry 119, 121, 211, 231, 274, 288, 400, 537, 550 pharmacists 84, 92, 276, 546, 600 pharmacology 21, 24, 164, 171, 193, 536, 539 pharmacopoeia 193, 197, 268, 274, 580 phenylketonuria (PKU) 234 philanthropic foundations 9–10, 230, 231, 234, 254–7, 312, 362–4, 421, 472, 516, 533, 572, 598, 600, 601, 621–2 philanthropy 104, 106, 157, 202, 229, 323, 413, 435, 438 Philip II, King 198 philosophy 27, 173, 175, 182, 477, 478, 527 Aristotelian 172 early modern medicine and 60, 62, 64 eighteenth-century medical training and 84 Greek medicine and 24–5, 33–5 Islamic medicine and 179–80, 183 Western European medicine and 193, 194 phlebotomy 65, 178 phlegm 29, 30, 32, 342 photography 618 phrenology 588 phthisis 272 physicians/doctors 22, 41, 171, 196, 232 abortion regulation 518 American 227, 228, 229, 231, 232, 235, 255 attending the deathbed 360–1 British 437 chronic illness and 399 colleges of 191 conflicts between 472 Confucian 159 court 33–4, 62, 66, 160, 179–80, 183, 199 ‘dietetic’ 192 early modern medicine 62, 63 Eastern Europe 213, 214 eighteenth-century 83, 84, 92

index experimental film 619–20, 628 fatalism towards the dying 364 female 490 female patients and 489, 491–2, 492 French 442, 443, 472 geriatric medicine 344–5 German 436–7, 438 guilds of 64, 85, 191, 195, 197, 227 Hindu 285 human experimentation 548–52 iatrochemistry 198 improving efficiency and productivity 105 Islamic 175, 178, 179, 180, 181, 182 Latin America 246, 250, 251, 252, 253, 257, 259 licensing 82, 83, 84, 85, 200, 228, 246, 547 medical ethics and 544, 545, 546, 563 medieval rural 46–7 national health insurance and 203 New York 546, 620 oral histories of 600–1 Portuguese 286 professional rivalries between 600, 601 punishment of professional misconduct 547–8, 549 rise of the modern male 488 rivalry with folk medicine in Latin America 251 scholastic medieval 40, 41, 42, 43, 44, 45, 47, 48, 49 Scottish 343–4 self-taught 179 Soviet 211 specialization 105–6 and surgeons 92 Swedish 435 on television and film 619, 627 physiology 28, 30, 41, 101, 107–8, 198, 202, 347, 398, 472, 533, 567–8 Pick, Daniel 107 Pickstone, John 479–80, 494, 545, 618 Pinel, Philippe 526, 528 Pisa, University of 66 Pitcairne, Archibald 90 placebos 45, 524, 536, 538, 551 plague 42, 83, 91, 176, 226, 253, 254, 288, 289, 294



Plato 24, 30, 33, 34, 61, 64, 173 Platt, Harold L. 457 Pliny the Elder 29, 61, 192, 193 Plumb, J. H. 5 pneumatic medicine 88–9, 90 pneumoconiosis 603 poisoning 157, 458, 550 Poland 209, 214, 216 Polanyi, K. 431 polio 121, 122, 233 political economy 11, 244, 266, 272, 275, 279, 376, 416, 429–46, 494 politics 82, 88, 101, 123, 158–60, 211–12, 225 Pols, Hans 304 Polsek, Darko 216 Ponty, Merleau 451 Pool, Ian 308 Poor Laws 362, 363, 368, 397, 402, 404, 419, 429, 434, 435, 529 Poovey, Mary 486 Popova, Kristina 215 population 91, 101, 193, 231, 236, 259, 376–7, 422, see also demography population movement 191–2, 194, 196, 200, 227, 272, 289–90, 377, see also immigration port control measures 250, 253, 254 Portelli, Alessandro 600 Porter, Dorothy 6, 303, 412, 424 Porter, Roy 1–2, 3, 82, 361, 488, 588, 589 on animals 561, 562 on medical ethics 544 on patients 275, 327, 627 on visual aspects of medicine 618 Portuguese imperialism 243, 245–6, 247, 248, 285, 286 postmodernism 6, 8, 9, 24, 100, 101, 109–13, 114 post-mortems 395, 398, 552, 565 poststructuralism 109 poverty 201, 202, 215, 225, 228, 362, 394, 395, 413, 415, 419, 435, 458, 487 Praxagoras 28 prayers 47, 49–50, 156, 158, 170, 176, 180, 182, 357, 358, 359, 361, 585 pregnancy 488, 517, 519 pregnancy testing 570, 601



index

prenatal care 247 Preston, Richard 422 Preston, Samuel and Haines, Michael 383 preventative medicine 230, 303, 450 Australia 310 colonial authorities 286 medieval period 42 Mexico 250–1 old age and 341, 348 Russia 212 Priestley, Joseph 88 Prins, Gwyn 275, 276, 279 print culture 62, 63, 69, 85, 86, 159, 287, 357 Prior, Lindsay 356 prisons 201, 294, 420 private medicine 109, 231, 232, 440, 442, 443, 444, 484 private/public spheres 204–5, 491, 494, 506, 602, 603 Proctor, R. N. 461 professionalization 30, 48, 191, 203, 257, 275, 417, 565 Australia 302 complementary medicine 586 of death 360, 367, 368 early modern medicine 61 geriatric medicine 345 of medical practitioners 433 paediatrics 327 Soviet Union 210 United States 230 professional misconduct 547–8 prognostications 152 prolongevity 347–9 prophetic medicine 170, 180, 181–2, 182, 183 prophylactics 30, 91, 141 prostitution 91, 486, 506–7, 508–9, 511–13, 520, 549 mandatory inspection for venereal disease 250, 421, 484, 507, 512, 513 Protestantism 61, 246, 357, 362 Protestant Reformation (1517–55/60) 61, 63, 196 Prussia 434, 472, 547–8, 549 psyche 10 adaptive 526, 532–4 historical 526, 529–31

inscribable 526, 527–9 statistical 526, 534–7 psychiatry 101, 103, 216, 217, 273, 415, 524, 526, 531, 535 adaption 534 asylums 530 Australia 313 child 330 cosmetic 537 homosexuality and 510, 511, 537, 604 identity formation 538 military 533 sexology 515 term first coined (1808) 527 women and 484, 485, 489, 491–2, 496, 507 psychoanalysis 273, 360, 526, 531, 532, 533, 535, 536 psychobiology 533 psychology 101, 228, 273, 327, 329, 330, 524, 525–6, 527, 531, 533, 535–6, 538 psychosomatics 526, 527, 533 psychotherapy 524, 526, 527, 528, 535 puberty, early onset 603 public health 6, 106, 201–2, 204, 205, 215, 410–24, 459, 472 American 226, 228, 229, 230, 233, 235 animals and 566 Australia and New Zealand 303–5, 310, 311, 313 bacteriology-based 458 chronic illness and 402 clinical medicine and 414, 450 contemporary history of 121, 122, 125, 126–7 critical social history of 416–22 disposal of bodies 366 Eastern European 213, 215 Edwin Chadwick and 418–19 eighteenth-century 91–2 environmental hazards and 456 epidemics and 412, 417, 419–20, 423, 424 epidemiology and 374, 380, 411, 412, 413, 414, 419–20, 423 Indian 290–3 Latin American 248–52, 255, 256, 260 mandatory inspection of prostitutes 250, 421, 484, 507, 512, 513

index midwives and 487 ‘narrowing thesis’ of 461 philanthropic foundations and 230 practitioners’ histories 413–16 Soviet Union and 210, 211, 212, see also vaccination; inoculation; environmental issues; sanitation Public Health Acts 419, 432 public relations campaigns 623 puerperal fever 487 puerperal insanity 491, 507 Puerto Rican migrants 234 Puerto Rico 243, 248, 255 pulse diagnosis 28, 153, 163, 584 purging 42, 565

qi, concept of 153, 154, 156, 163 Qin dynasty 151 Qing dynasty 161–2 Qinshi Huangdi, Emperor 151 quackery 42, 62, 65, 246, 348, 508, 513, 578, 579, 580, 592 quality of life 26, 348 quarantine 196, 233, 250, 253, 290, 311, 360, 374, 380 questionnaires 535–6 quinine 161, 295, 360 Quinlan, Karen 554

rabbits 568 rabies vaccine 568 Rabinbach, Anson 100–1 race 88, 128, 191, 232–5, 383, 487 Rachieru, Silvana 215 racism 225, 233, 235, 272, 278, 309–12, 421, 513 radiation experiments 548 radiotherapy 438 railways 101, 107 Ramasubban, Radhika 291, 292 Randic, Mirjana 214 Ranger, Terence 271 Raphael, Beverly 360 rationality 23, 26, 104, 182, 190, 582 death 359



Greek medicine 30–1 hygiene and 87, 102 magic’s juxtaposition with 176 Weberian modernity and 102, 104, 106, 109, 110, 111, 114 Raume, Geoffrey 604 al-Rāzi 171, 174, 175, 176, 177, 178, 180, 194 RCTs (randomized controlled trials) 536, 584–5, 587 Reagan, President Ronald 443 Red Emperor (Divine Farmer) 151 Reed, Walter 253 Rees, Linford 536 reflexivity 478, 525–6, 536, 537, 538 regimen medicine 86–7 regionalism 128, 228 regulation of medicine 84, 101, 107, 195–6, 553 Reil, Johann Christian 527 Reinarz, Jonathan 322 religion 23, 27, 588, 592 African 268, 270–1 Chinese medicine and 156–8 death and 355, 356–9, 360, 361, 362–3, 366–7 early modern medicine and 61 hygiene rituals and 182 Indian 270–1, 287 Islamic 172–4, 190, 270, 289–90 Lourdes 277 medicine and 23–4, 30–1, 49–50, 176 wars of 61, 63 Western European medicine and 192, see also Catholic Church; Protestantism Renaissance 40, 41, 43, 44, 55, 61, 102, 190, 191, 196, 342, 347, 564 Republic of Letters 62 Research Ethics Committee 607 respiratory diseases 293, 382, 384, 402 resuscitation 31 Réti, Endre 216 rheumatism 342 Rhijne, Wilhelm Ten 584 Richards, Jeffrey 622 Richards, Wendy 603 Richell, Judith 293 Riley, James 379



index

Ritzmann, I. 328 Rivers, Tom 600–1 Rivkin-Fish, Michele 211 Robinson, Nicholas 343 Rockefeller Foundation 213, 215, 230, 231, 234, 254–6, 257, 312, 421, 472, 516, 533, 572 Roelcke, Volker 551 Roe v. Wade abortion case (1973) 554 Rogers, Naomi 233, 589, 618 Roman Empire 28, 29, 35, 190, 192–3, 194, 197, 341, 582, see also Graeco–Roman medicine Romania 118, 209, 214, 215, 216 Romanov, Pavel 212 Romanticism, and death 359, 365 Roosevelt, President Franklin Delano 232, 437 Rosen, George 11, 414, 415, 416 Rosenberg, Charles 8, 231–2, 233, 235–6, 393 Rosenthal, Franz 179 Rosner, David and Markowitz, Gerald 126, 452, 453, 458 Ross, Edward A. 232–3 Rothman, David J. 126, 552 Rothstein, William G. 459 Routledge Studies in the Social History of Medicine 208 Rowntree, Seebohm 413 Royal College of Physicians, London 64, 123, 402 Royal College of Surgeons, London 84, 626 Royal Society, London 479 Royal Southern Hospital, Liverpool 105 Rudolf II, Emperor 66, 197 Rufus 174, 175 Ruland the Elder, Martin 66 Russett, Cynthia Eagle 489 Russia 208, 217, 218 contraception 519 history of medicine in 210–13 laboratory medicine 103, see also Soviet Union Ryle, John 6, 414

Sabin polio vaccine (OPV) 122 sadism 504, 514 Said, Edward 579

Salamanca 66 Salernitan reform 471 Salerno medical school 41, 44 Salk polio vaccine (IPV) 122 Salvador da Bahia group 252 Samuel, Raphael 598 Sand, René 415 Sandinista revolution (1979) 260 Sanger, Margaret 509 sanitation 250, 457 Aztecs 247 disposal of the dead 360, 365–7 India 290–3 inspection 303 international cooperation and 254 Latin America 247–8, 256–7 public health and 418–20 regulations 412 religious pilgrimages 290 vermin control 566, see also public health Santasofia, Marsilio 64 Sargant, William 535, 538 Sarton, George 470, 471, 473 Sauerteig, Lutz 329 Saunders, Cicely 364–5 Sâvaji, Mirzâ Musâ 176, 180 Savitt, Todd 229 Savonarola, Michele 66 Scania 377 scarlet fever 357 Schäfer, Daniel 347 Schaffer, Károly 216, 217 Schiebinger, Londa L. 585 Schilde, Kurt 214 Schivelbusch, Wolfgang 101 schizophrenia 525, 533, 534 Schleiden, Matthias 202 Schmidt, Ulf 619 Schoepflin, Rennie 588 Schofield, Roger 380 scholastic medicine 40–6, 47, 49, 51, 55, 102 Schou, Morgens 536 Schulte, Dagmar 214 Schuster, Paul 620 Schwann, Theodore 202 Schweber, Libby 376

index science 113, 121, 172–4, 190, 229, 287, 469–80 scientific instruments 476–7 scientific knowledge 87, 211, 212, 213, 477, 479 scientific management 104–5, 107, 111 scientific medicine 108, 202–3, 230–1, 271, 413, 420, 459–60, 469–80, 586, see also Western medicine scientific revolutions 471–4, 476, 478 Scott, Joan 485 Scottish Society of the History of Medicine 3, 4 Scull, Andrew 529 scurvy 89, 395 seasonal illness 172 Second World War (1939–45) 108, 109, 117 children evacuees 323 eugenics 216–17 famine 386 health education films 623 homosexuality 511 human experimentation 550–1 secularization 87, 88, 582 Seidler, E. 321 Selden, Anthony 118 self-help therapies 279, 492, 580, 592, 602 Self-Strengthening Movement 162 Selikoff, Irving 453 Sellers, Christopher 11, 122 Selye, Hans 533 Semmelweis, Ignaz 201 senile dementia 344, see also old age Serbia 214 serology 414, 476 Seventh Day Adventist Church 587 Sewell, Mary 358 sewerage 201, 457, see also sanitation sex education 329, 516–17, 519 sexism 421 sexology 514–16 sexual health 119, 120 sexual intercourse 33, 179 sexuality 68, 90, 119, 244, 423, 479, 488, 496, 503–20, 607 female 486, 505–9, 520 history of 120 male 509–11 permissive society 517–19 and power 211, 504, 505



science of 514–17 voluntary organizations 516, 519, 520 sexually transmitted disease, see venereal disease Sexual Offences Act (1967) 511 sexual revolution 509, 517–19 Sforza, Galeazzo Maria 66 Shah, Nayan 458 Shahar, Shulamith 340 shamans 285, 585 Shams al-Din al Zahabi 181 Shang dynasty 150 Shangqing school 157 Shapin, Steven and Schaffer, Simon 479 Sharif, Hakim Mohammad 171, 178, 186 n.48 shell shock 110, 532 Shkimba, Margaret and Flynn, Karen 600 Shorter, Edward 488, 538 Showalter, Elaine 491 Sibyls 340 ‘sick building syndrome’ 454 sickle cell anaemia 234–5 SIDA (Swedish International Development Agency) 139, 140, 142 siddha medicine 285 Sigerist, Henry E. 210, 225–6, 231, 415, 469, 470, 471, 479 Sikhs 287 Silesian typhus epidemic (1848) 414, 416 Silla, Eric 279 Simon, John 413, 414 Simpson, Pat 211 Sinān b. Thābit b. Qurra, see Bin Qurra, Sinān b. Thābit Singer, Aubrey 625 Sino-Japanese war (1894–5) 162 Sivaramakrishnan, Kavita 287 skin grafts 572 Skinner, B. F. 536 slaves/slavery 89, 228–9, 246, 247, 266, 271, 413 sleep 33, 186 n.56, 348 sleeping sickness 272, 275 Slovenia 118, 214, 215 Smail, Daniel Lord, On Deep History and the Brain 113



index

smallpox 199, 226, 227, 357, 420 Chinese medicine 161 eradication programmes 137–45, 248, 258–9, 292 in India 288–9 inoculation 91, 108 in Latin America 245, 248, 258–9 pandemics 363 prevention 383 vaccination 137–8, 140–1, 143, 292, 293, 566–7 Smirk, Frederick Horace 401 Smith, F. B. 420 Smith, Glenn 604 Smith, Glenn et al. 602 Smith, Graham 600 Smith, Matthew 331 Smith, Philippa Mein 311 Smith, Russell G. 547 Smith, Susan 487 Smith-Rosenberg, Carroll 492 smoking 120–1, 126–7, 384, 402, 422, 424, 446, 460, see also tobacco industry Snow, John 419–20 social change 85, 518–19, 552 social class 87, 191, 260, 362, 374, 418, 431, 491, 492, 494, 496, 506, 508, 512 social constructionism 7, 8, 304, 305, 504 social democracy 431, 432, 435, 436, 437, 442 social engineering 211, 327, 472 social history 4–8, 13, 22, 23, 25, 82, 83, 119, 126, 162, 184, 244, 373, 396, 453, 463, 470, 598, 628 of alternative medicine 579–80, 588, 589, 590 of animal experiments 569 of children 321, 324, 329, 331, 332 of early modern medicine 65, 71 of Eastern Europe 209, 215, 217 environmental history and 457 of industrial hazards 452 Islamic 184 oral testimony and 598, 602 patient-centred approaches to 328 place and 451 public health and 303–5, 416–22 Rome 28 of sexuality 503–4 women studies 484 Social History of Medicine (SHM) 119, 277, 304

socialism 257, 404, 430, 436 social medicine 259–60, 261, 292, 412, 415, 416, 417, 418 social policy 323, 324, 326, 413 social protectionism 215 social sciences 414, 416, 421 social work 212, 215 Société Royale de Médécine 86 sociology 373, 393, 460, 532–3, 581, 589, 606 Solomon, Susan Gross 210, 211, 212 Somalia 143 Song dynasty 156, 158–60 Sontag, Susan 395, 405–6 Sophocles 31 Sorokina, Marina 212 Sorokina, Tatyana S. 212 soul 32–3, 34, 54, 90, 158, 173, 199, 200, 357, 358, 359, 362 South Africa 120, 122, 266, 269, 270, 272, 273, 274, 275, 276, 277–8, 279, 454 South Asia 285–96, 582, 592 Soviet Union 208, 210–13, 214 eugenics 216 gerontology 345 global smallpox eradication programme 140–1 influence in Latin America 257–9 Leningrad siege (1942–3) 386 public health 415, see also Russia Spanish-American War (1898) 253 Spanish imperialism 243, 245–8, 247 Spanish Influenza (1918) 303, 385, 610 specialization 84, 105–6, 108, 327, 484–5, 489 spice trade 193, 196 spiritism 246, 249, 250 spirits/spirit healing: Aboriginal 306 Chinese medicine 150, 153, 154, 156, 159 Islamic medicine 170, 172, 176, 182 Latin America 246, 249, 266 South Asia 287 Sub-Saharan Africa 266, 268, 269, 270, 271, see also alternative medicine spiritualism 362, 367, 531 Spock, Benjamin 495 Sri Lanka (Ceylon) 377, 383, 582 SSHM (Society for the Social History of Medicine) 3, 4, 6, 12

index Stahl, Georg Ernst 90, 199 Staley, Kathryn 608 Stalin, Joseph 415 Stampar, Andrija 214 standard of living 418 statism 415, 417, 423 statistical studies 201, 535, 536 Stein, Claudia 618 Stekel, Wilhelm 532 stem cell science 554 sterilization 550 stethoscopes 398 Stevens, Rosemary 232 Stewart, John 322, 330 Still, Andrew Taylor 587 Still, George Frederick 321 stillbirths 355, 376 Stoicism 35 Stolberg, Michael 346 Stopes, Marie 509, 515 Storch, Johann 488 Stradling, David 458 streptomycin 401 stress 395, 454, 527, 533, 534, 602 strokes 384, 402, 603 Stuart, Annie 312 Styrap, Jukes de 547 Sub-Saharan Africa 266–80, 386 suburbanization 384 Sudhoff, Karl 44 suicide 273, 358, 532 Sui dynasty 158 Sullivan, Harry Stack 533 Sun Simiao 157 superstition 23, 24, 42 surgeons 42, 48, 54, 92, 472, 565 American 227 eighteenth-century 83, 84 guilds 195 and physicians 92 specialization 106 television and 627, see also physicians/ doctors surgery 161, 175, 203, 534 ancient Chinese 155 battle wounds and 178, 199 gynaecological 490 Islamic 176–9



medieval techniques 44 mutilating female 488, 507 open-heart 626 on television 626–7 thoracic 401 transplant 553, 572, 601 surgical instruments 62, 178–9 surveillance 91, 138, 139, 260, 419, 421, 511 Suzuki, Akihito 491 Swahili medicine 270 Swallow, Norman 626 Sweden 118, 120, 140, 203, 384 global smallpox eradication programme 139 life expectancy 341 population health indicators comparison 444–6 pre-welfare state 434, 435 welfare system 430, 432, 433, 437, 440–1, 442–3 Switzerland 140, 341 Sylvester II, Pope 193 Sylvius, Franz de le Boë 198 Sylvius, Jacobus (Jacques Dubois) 63 sympathetic magic 176 syncretism 244, 246, 251 syphilis 120, 197, 215, 235, 394, 474, 476, 511, 538 Africa 272 human experimentation 549 Tuskegee Syphilis Experiment 120, 235, 414, 421, 548, 551, 609 Wasserman test 249, 476, 525 systematic desensitization 536 Szabo, Jason 393 Szasz, Thomas 82, 538 Szikra, Dorottya 215 Szreter, Simon 11, 376, 380, 418

Talbot, Charles 44 talismanic healing 156, 181 Tang dynasty 157, 158, 159 Tanner, Andrea 322, 329 Tannstetter, Georg 66 tantrism 285 Tanzania 610 Tao Hongjing 157



index

Tarr, Joel A. 457, 458 Tata, J. R. D. 142 Taylor, Frederick 104 Tay-Sachs 234 TCM (traditional Chinese medicine) 150, 153, see also China; Chinese medicine teenagers 329, 517, 519, 554 teeth 46, 47, 71, 84, 90, 202, 338, 342, 343, 347 Teleky, Ludwig 452 television and film 617, 618–19, 623, 624–7, 629 terminal illness 360, 361, 363–4, 367 thalidomide tragedy 102, 121 Thatcher, Margaret 109 therapeutics 109, 171, 247, 277, 578 Theriot, Nancy 492 thermodynamics 473 Thirty Years War (1618–48) 61, 65, 69 Thomas, David 308 Thomas, Keith 349–50, 503 Thomas, Lynn 278 Thomas, W. I. 533 Thompson, Dr J. A. 313 Thompson, E. P. 288, 418, 419, 421 Thompson, Paul 598 Thompson, Sir Henry 366 Thomson, Samuel 585, 587 Thornton, Russell 226 thought collectives 474–7 thrifty phenotype hypothesis 384 Tianjin, Treaty of (1858) 161 Ṭibb al-Nabbi (Medicine of the Prophet) 170, 181 Tibet 160, 582 Tinker, Hugh 291 Tissot, Samuel-André 86 Tithonus 340 tobacco consumption 422, 446, see also smoking tobacco industry 120, 124, 126 Tocqueville, Alexis de 225 Toma, Valentin-Veron 215 Tomes, Nancy 495, 598, 599 Toms, Jonathan 8–9 tonsillectomies 326 toothache, see teeth Townsend, Peter 125 toxicology 157, 454, 458–9, 460, 462, 570 trachoma 233

trade unionism 436, 437, 438, 452, 453 transnationalism 303, 313–14 transplant surgery 553, 572, 601 Transylvania 214 travel 138–40, 147 n.14, 180 Treaty of Waitangi Act (1974) 308 Trevan, J. W. 570 tropical medicine 249, 252–4, 271, 272, 309–10 Truman, President Harry 258 trypanosomiasis 252 tuberculin 401 tuberculosis 121, 122, 293, 311, 382, 401–2, 420, 568, 570 adverse conditions during childhood and 384 Africa 272 Bulgaria 215 consumption and 394, 395 oral testimony of 602 public health and 424 studies 236 Tuke, Daniel Hack 526 Tuke, William 528 Tunisia 183 Turda, Marius 216 Turkey 183 Turner and Newall (asbestos company) 454 Turow, Joseph 619 Tuskegee Syphilis Experiment 120, 235, 414, 421, 548, 551, 609 Tuve, Jeannete 210 Tweedale, Geoffrey and McCulloch, Jock 454 twentieth century 23, 102, 119 children’s medicine 325, 330 Chinese medicine 162 chronic illness 394, 401, 402, 406 death in 359–60, 362, 365, 367, 368 demography 375, 382, 383 Eastern Europe 214, 216, 217 Galenico-Islamic medicine and 183 human experiments 212 malaria studies 292 medicalization of Western Europe 203–4 old age and 341, 343–5, 346, 348 patient’s perspective 54 post-colonial medicine 273 postmodernism 109, 111

index public health 121, 144, 230, 255, 256, 293, 295, 303, 306, 313 social medicine 416 women 484, 485, 487, 495–6, see also welfare state; occupational health; sexuality ; First World War; Second World War typhoid 108, 382, 609 typhus 210, 226, 233, 357, 414, 416, 420

Ullmann, M. 172–3 unani medicine 60, 287, 288 unconscious 530–1, 532 UNICEF (United Nations Children’s Fund) 136, 258 United Nations 625 United States 4, 6, 161, 190, 306, 377, 384, 433 AIDS in 118–19, 120 Alexis de Tocqueville on 225 AMA code of ethics 544, 545, 546, 547 anti-abortion campaign in 518 bioethics 552, 554 black midwives in 487 Centers for Disease Control in 145 child abuse in 325 child welfare in 323 Chinese medical practitioners in 586 chronic illness in 402–4 contemporary history of medicine in 119, 122, 124, 126, 127 DDT spraying in 460, 462 demography of 383 disease introduced by settlers in 226–7 environmental history of 456, 457–8 ethics and data protection in 555, 606–8 focus on empiricism in 228, 229 genetics in 234–5 global smallpox eradication programme 138, 139, 140, 141 health care reform in 122, 443–4 health insurance in 231–2, 430 Henry Sigerist on 226 homoeopathy in 589 hospitals in 104, 438, 490 indigenous people in 307



industrial health in 453, 454 infant feeding in 495 influence in Latin America 243, 244, 253, 257, 258 medical training in 229 Medicare/Medicaid 430, 441, 442, 443 mutualist associations in 435 New Deal Program 232, 437 Obama health care legislation 232 occupation of Japan 441 old age in 341, 345 oral histories of health and medicine 598, 600 Panama Canal and 253–4 pluralism 231 population health indicators comparison 444–6 prostitution in 507 public ‘almshouses’ 435 public health in 383–4, 419 race and disease 232–4, 383, 421, 458 race and midwifery 487 rejection of national health insurance in 432, 437–8, 441, 444 Roe v. Wade abortion case (1973) 554 sexology 515 tobacco industry archives 124 Tuskegee Syphilis Experiment 120, 235, 414, 421, 548, 551, 609 unique diseases in the South 228–9, 230 war with Spain (1898) 253, see also Rockefeller Foundation universalism 430, 433, 443, 590 universities 46, 60, 64, 191, 471–2 American 229 and corporations 195–6 court medicine and 66 early modern medicine 62, 64, 65, 66 eighteenth-century 83, 84 founding of early 195 laboratory teams 202 materialism and 198–9 medieval 41, 42 paediatrics 327 research 472 Scottish 313 Uppsala, University of 60, 67



index

urban health 456–9, see also cities urbanization 159, 200, 375, 377, 382 uroscopy 43, 44, 65, 399 Uruguay 253, 258, 260, 261, 375 USAID (US Agency for International Development) 139

vaccination 199, 248, 272, 569 campaigns 122 certificates 139, 311 health education films 621 introduced to China 162 mandatory 250 and ‘moral panics’ 278 public health 421–2 rejected on cultural grounds 288–9 smallpox 137–8, 140–1, 143, 292, 293, 566–7 Valencia 66, 67 Valencius, Conovery Bolton 459 Valéry, Paul 106 vampirism 91 Van der Eijk, Philip 10 Van de Velde, Theodoor Hendrik 510, 515 Van Helmont, Joan Baptista 198 variola, see smallpox variolation 161–2 Varsa, Eszter 215 Vaughan, Megan 271–2, 275–6, 278–9, 305, 309 vegetarianism 87, 491 venereal disease 294, 312, 363, 417, 486, 511–14, 517, 519, 549, 568, 622 antibiotics 517 health education films 622, 623 human experimentation 549 prevention policies 421, see also syphilis venereology 516 Venezuela 248, 255, 256, 258, 259, 260, 261 Verbitski, Vladimir M. 212 Vesalius, Andreas 63, 64, 65, 67, 102, 110, 198 veterinary medicine 276, 561–73 Veterinary Record 572 Veyne, Paul 64 Victoria, Queen 506 Viel, Dr. Benjamin 258

Vienna 201, 620 Vienna Circle 477 Villermé, Louis-René 201, 382 Vimercati, Raffaele 66 Virchow, Rudolph 202, 382, 414, 416, 546 virginity 509, 518 virology 600–1 vitalism 90, 198, 344, 478 vitamins 569 vivisection 28, 177, 549, 563, 564, 567, 568 voluntary euthanasia, see euthanasia vulture medicine 51–3

Waaldijk, Berteke 215 Waardt, Hans de 588 Wailoo, Keith 234, 235, 236 Walker, David 309 Walker, George 365–6 Walter, Tony 368 Walter, William Grey 534 Wang Anshi 159 Wanhalla, Angela 306 warfare 106–9, 114, 229, 379, 512, 534, see also First World War; Second World War Warner, John Harley 228, 229, 459, 470, 546 Warren, Christian 458 Warren, Marjorie 345 Warring States period 150, 151, 153 Washington, Sylvia Hood 457 Wasserman test 249, 476, 525 water pollution 458 water supplies 457 Watkins, Robert 620 Watson, John B. 536 Watson, Professor Robert Seton 117 Watt, Montgomery 172 Watts, Sheldon 290 Way of the Celestial Masters 157 Wear, Andrew 546 Webb, Beatrice 339, 413, 414, 419 Webb, Sidney 413, 414, 419 Weber, Max 100, 103–6, 108, 109, 110, 111, 114 Webster, Charles 6, 7 Weindling, Paul 452, 607 Weisse, Alan 600

index Weisz, George M. 305 welfare states 303, 387, 429 chronic illness and 401–5 ‘crisis’ of the 442–4 Eastern Europe 215 health systems in 436–42 population health indicators comparison 444–6 precursors to 434–5 theorizing 431–3 Wellcome Trust 3, 4, 9–10, 472, 570, 572, 598, 600, 601 Wells, Thomas Spencer 490 Welshman, John 322 Wentworth, Lady Isabella 339 Wesley, John 86, 90 West, Harry 276 Western medicine 190–205, 279, 305, 405, 579, 581 child health 332 corporations and formulations 194–200 early modern 60–72 and indigenous people 306 Japan and 435 nation-state and medicalization 200–4 ‘theory of itself ’ 275, see also scientific medicine West Germany 140, 440, 441, 548 wet-nursing 85, 245 White, Ellen G. 587 White, Hayden 113 White, Luise 278 WHO (World Health Organization) 122, 136, 137–45, 248, 254, 258–9, 292, 379, 514, 619, 625 whooping cough 326 Whorton, James 589 Wiener, Norbert 534 Wilde, Oscar 510 Wilkinson, Richard 412 Williams, Andrew 322 Williams, Raymond 102 Willis, Thomas 399 Wilson, Adrian 493 Winslow, C.-E. A. 414 Winter, Alison 588 ‘wise-women’ 43, 47, 84, 85, 194, 285



witchcraft 63, 269, 270, 271, 272, 273, 485, 486, 487–8, see also magic Withering, William 199 Wolfenden Committee (1954–7) 511 Wolpe, Joseph 536 wombs 46, 47, 247, 489, 508 women 324, 484–96 alternative medicine 490–1 ‘amateur’ prostitutes 508–9, 512 domestic health care 494 egg donors 554 healers 47, 85, 156 health of young 495 life expectancy 381–2 menopause 340, 346–7, 488 mental health 602 motherhood 485, 488, 491, 508, 605 old age 340 and psychiatry 484, 485, 489, 491–2, 496, 507 public health 417 severe malnutrition and anovulation 385 ‘wise-women’ 43, 47, 84, 85, 194, 285, see also childbirth; prostitution Wood, Ann Douglas 489 Wood, Pamela 311 Woods, Abigail 127 Woods, Robert 12, 374, 375, 380 workhouses 362, 404, 435, 438 working class 234, 434, 457, 487, 492, 506, 520 death 357, 362, 368 keeping animals in urban conditions 566 medicine and 363 nineteenth-century conditions 201, 396 oral testimony 602, 609 World Bank 260 World Health Day 139 World Medical Association 550 Wright, David 491 Wrigley, Tony 380

Xenocrates of Aphrodisias 176 xenotransplantation 572 X-rays 203, 438



index

Yahya b. Isā b. Jazlah, see Bin Jazlah, Yahya b. Isā yaws 272 Yellow Emperor canon 150, 152–4, 153, 155 yellow fever 226, 227, 228, 248, 250, 251, 253, 255, 420 Yellow Turbans sect 156 yin and yang 153, 154, 155, 156 Young, Edward 365 Your Life in Their Hands (television series) 625–6, 629 Yuan dynasty 159, 161

Yudin, Boris 212 Yugoslavia 139, 141, 209, 214 Yunnan 386

al-Zahrāwi, Abul-Qāsim (Albucasis) 177, 178–9 Zambia 141, 271 Zerbi, Gabriele de 545 Zhang Zhongjing 155–6, 159 Zhou dynasty 151 Zoroastrianism 172, 173 Zurich 328