Introduction

The first act of the historian, the act which constitutes all the history (s)he subsequently writes, is to decide to write the history of something. That ‘something’ is naturally, normally, taken from the world around us, the world of which the historian is a part. And so it is that in roughly the last hundred years we have had histories of midwifery, of obstetrics, and of their professions – female midwives, male obstetricians. The writing of the histories coincides with the existence of these present realities of which the histories have been written. Such history-writing forms a specimen both of ‘tunnel history’ and of ‘present-centred history’. Equally, and of special concern in the present volume, it is ‘iatrocentric’: that is to say, histories of, say, obstetrics are inevitably written from the viewpoint of the obstetrician. The survival of evidence in handy packages (treatises of obstetrics/midwifery, written mainly by men) conspires with the attitude of the historian to perpetuate this state of affairs. There is an overwhelming tendency to see the story as a technical matter, to dignify the techniques therefore with a special status, and thus to end not only with a whiggish history of inevitable ‘progress’ (the present day being the age of perfected technique), but also with an account which excludes the viewpoint of the very people who must have been at the heart of the story: the women who actually gave birth to our ancestors.

For the nineteenth century the history of English medicine has long since ceased to be written as though it were simply the annals of heroic doctors and epoch-making breakthroughs. That old warhorse, the epic of medical progress, featuring The Revolution in Victorian Medicine and the consequent deliverance (as two recent popular books put it) from The Age of Agony to The Age of Miracles, has for some time now been comprehensively challenged by a variety of alternative ways of seeing.

For example, complementing Ackerknecht's work, the late Michel Foucault argued that The Birth of the Clinic spelt a revolution in ‘medical gaze’, with the new normative and technological order of the hospital entailing fresh diagnostic epistemologies and disease representations, all generating vast medical power. Paralleling and to some degree overlapping with Foucault, many medical sociologists have trained their spotlight on professionalization as the great dynamo of medical transformation. Their timely attention to professional ambitions further reminds us that the Victorian age saw the rise of the public health movement, and other critical encounters in medicine's equivocal relations with the state; and this in turn has implications for what one school of investigators has dubbed the ‘medicalization of life’ – a concept often linked with polemical exposés of the ‘disabling professions’ and ‘the expropriation of health’, and with a radical desire to demystify medicine's allegedly hegemonic role as a secular and naturalizing instrument of ‘social control’. Of course, as ‘medicalization’ proceeded and orthodoxy sandbagged its citadel in the Victorian age, ‘alternative’ medical therapies became steadily more marginalized; and awareness of this polarization has informed recent explorations of radical and plebeian medicine.

Introduction

Not many historians so far have examined Puritan attitudes to physical illness. A lot of the contextual spadework, however, has already been done by social, cultural, political, religious and demographic historians. They provide the larger picture in which to place the subject and they also help to illuminate related issues (for instance, the spiritualisation of life, providence, the different shades of Puritanism, the material conditions of society, etc.). Moreover, thanatology has recently become popular. As death was often the expected consequence of illness in the seventeenth century, people's attitudes to it had a close relationship to their perceptions of illness.

Attitudes to illness itself have been studied by Keith Thomas and Alan Macfarlane. Both bring out the importance of providence as a means by which Puritans made sense of illness. Thomas also provides an influential and important overview of cultural change in seventeenth century England that shows magic declining with a trend towards secularisation after the Restoration. It may be, as Jonathan Barry points out in this volume, that secularisation was not as rapid or as clear-cut as some historians, following Thomas, have imagined. Also, more specifically, the case for providentialism may have been overemphasised, and in this essay I shall spell out in detail the nature of the eclectic use of physical and religious explanations of illness.

Psychological illness in the seventeenth century has received some recent attention.

The fifth Abbasid caliph, Harun al-Rashid, had three wives whose beauty, grace and wit were legendary. At the same time, he also had a short, fat, ugly cook named Murjana. One day, while this Murjana was out in the fields, she came across the body of a dead horse surrounded by wild animals. To her surprise, however, not a single animal would come near the carcass. Murjana decided to investigate. When she reached the body, she found a charm hanging about its neck which she removed forthwith and hung about her own neck. No sooner had she done this than the wild beasts sprang onto the horse and began to devour it. When she reached the palace, her beauty amazed all who saw her, not least the caliph who became so enamoured that he married her at once, neglecting all his other wives. Not long after, poor Murjana sickened and died. The caliph was inconsolable. However, the woman who was washing the body before burial came across the charm. She instantly donned it and was, in her turn, transformed such that, when Harun saw her, he forgot all about Murjana and married her on the spot.

This unhistorical but colourful story formed the substance of a favourite Arabic charm widely used throughout the Levant by the peasants during the early part of this century. It was written on paper and wrapped in cloth and, when worn around the neck, it was supposed to confer the same sort of luck on its wearer as befell Murjana and her successor.

Doing justice to the patient's view is a precarious undertaking because it is a journey to uncharted regions. To help find our bearings, maps for analysis may be borrowed: those histories which have interpreted for us the work of physicians, their knowledge of diseases, or the medical profession's turning towards the hospital as a place wherein patients and their diseases are most efficiently scrutinized. But even if a patient is liable to accept with one part of his mind the medical version of what ails him, many another aspect of illness will turn to haunt the mind and the emotions, and precipitate an interpretation inconsistent with the more or less neat, and therefore also reassuring, pattern of medical analysis, with its diagnostic and prognostic functions.

In attempting a foray into such a land of variations, the only guideline will be the subjective view, the actions and thoughts of individuals as they are faced with suffering and bodily weakness. Subjective reactions are certainly conditioned by society and by personal values which temper what is done or left undone. The quirks of human nature are often most apparent in the face of unknown or dangerous situations. Whether one is stoic, frightened, resigned, disparaging or resolute can be conditioned, or it can be a response which breaks the mould. All it ultimately tells us about is how life was dealt with, but this, in itself, is an aid to interpretation.

In the concluding chapter of Religion and the Decline of Magic Keith Thomas describes the ‘decline of magic’ after 1660, replaced by a range of practical, scientific and medical methods to counter, or at least mitigate, the uncertainties of life, amongst which illness was the most persistent. Historians of medicine have generally endorsed Thomas' view that medical remedies grew in importance in the eighteenth century, at the expense of religious or magical means of healing. In and around the towns at least the qualified medical man replaced the minister as the chief healer, whilst patent medicines, endorsed by medical men, proliferated at the expense of home-made cures. In the key areas of witchcraft and mental illness moral and religious explanations of disease gave way, in official circles at least, to more secular, materialistic accounts. Thomas suggests that such developments resulted in a widening gap between popular and elite notions, as the rural poor clung to their traditional remedies and magical beliefs, now dismissed as vulgar superstitions by the educated.

Thomas and other historians have been more confident in describing this process than in explaining it. Thomas rightly dismisses the notion that medicine or science had decisively demonstrated their superiority, concluding that ‘in medicine as elsewhere, therefore, supernatural theories went out before effective techniques came in’. Thomas is forced to suggest, tentatively, a revolution of aspirations, linked to a new scientific worldview.

We have histories of diseases but not of health, biographies of doctors but not of the sick. Admittedly, in recent years in particular, a barrage of attacks has been mounted against the ways scholars have traditionally conceived the history of medicine. The discipline (critics allege) has been too Whiggish, too scientistic, either deliberately fostering or at least unconsciously underwriting myths of the triumphal cavalcade of scientific medicine. And in response strenuous counter attempts have been made to ‘demystify’ medical history, and to promote research oriented towards new ways of seeing, in particular examining the socio-cultural construction of medical knowledge and medicine's role within wider networks of ideology and power. As yet, however, these winds of change have rarely led to much attention being paid to the objects of medicine, the recipients of ‘the clinical gaze’, the sufferers.

Indeed, perhaps ironically, these new and critical forays into medical history often end up by silently reinforcing that old stereotype of the sick, i.e. their basic invisibility. Traditional history of medicine simply ignored the patient. After all, it was what the doctor did to, and for, the sick that counted; the patient was just the raw material, the unwitting bearer of a disease or lesion. After all, no one ever suggested that historians of sculpture should concentrate on slabs of marble. Traditional history of medicine thus ignored the patient: he or she was of no interest. Modern critical histories, by contrast, still ignore the patient but often by design; for they sometimes argue (as has David Armstrong, following Foucault) that there can be no such material person as the ‘patient’, directly accessible to the historian.

The publication in 1724 of Richard Mead's Harveian oration of the previous year provoked a vigorous and instructive controversy. Relying largely upon the evidence of a series of coins struck at Smyrna in Asia Minor, Mead argued that doctors in ancient Rome and its empire were men of education and high social standing, worthy precursors of the London College of Physicians. Ancient allegations of incompetence and corruption he referred to the servile practitioners of surgery, not to the physicians. Retribution was not long in coming. Conyers Middleton, theologian, librarian and unstinting controversialist, retorted that, whatever the situation in Greek Smyrna, the doctor in Rome and Italy was often a slave or an ex-slave, who fully deserved all the criticism heaped upon him and his fellows. In the pamphlet war that followed, Middleton more than held his ground, and there have been few since to question his basic division between the Greeks and the Romans over their attitudes towards medicine and physicians, or his assertion of the generally low social status of all medical men in Rome. In the subsequent two and a half centuries scholars have added little to his conclusions and few have commanded his wide range of learning. In their attempts to answer the seductive question of what the Romans thought of their physicians, prejudice has often been canonised as fact, and a traditional commonplace dignified with the title of insight.

The two classic divisions of European medical science are those of prevention and cure; and if we wish to look at the normally healthy individual in historical perspective we are speaking the language and regime of prevention. By far the larger part of individual health care is taken up by routine private maintenance, compared with which any curative intervention is an occasional public crisis. But the very nature of a multitude of low-level, dispersed acts has meant that the processes of prevention have not been as ‘visible’ to historians as the processes of cure. Investigation is further hampered by the fact that prevention has very rarely been of prime professional interest; preventive medicine was not even truly called ‘medicine’ as such. Medical historians have regarded therapeutics in general as ‘ an awkward piece of business’; and prevention in particular as a ‘murky bog of routinism’. Prevention, moreover, is and was barely newsworthy, being a passive or negative operation; in comparison, the combative techniques and reported statistics, the public and private cost of illness, are relatively accessible to the historian. Demographers and structuralist medical historians have taken disease beyond the supposedly inflated claims of curative medicine – ‘the emphasis on disease has great possibilities for it gets outside the narrow field of clinical medicine as practised by doctors’. The full range of preventive or survival techniques, however, has not so far caught the attention either of demographers or of historians.

The concept of ‘neurosis’ was coined by William Cullen, the Scottish physician, and appeared first in his Synopsis Nosologiae Methodicae (1769) and then in his First Lines of the Practice of Physick (1777). In studies published between 1835 and 1841 three followers of the German Romanticism have disagreed with this fact and attributed the term to Felix Platter, the Swiss physician of the Renaissance. This dissenting view, however, is based upon a misinterpretation of the term ‘functionum laesiones’, utilized by Platter in his treatise of practical medicine. For Cullen the term ‘neurosis’ was no more than a useful neologism with which to refer to ‘nervous disease’, a concept current in the medicine of his time. Its meaning then, vastly different from the one in usage nowadays, embodies a view of neurosis that had currency before its anatomoclinical re-interpretation.

That the term ‘nervous disease’ had originated a century before was common knowledge amongst the writers who modified it during the second half of the eighteenth century and a number of studies available during Cullen's time echoed views from a British tradition that had been started by Willis and Sydenham. Cullen stated in Synopsis (IV, p. 182) ‘Since the time of Willis, British physicians have grouped some diseases under the category of nervous’. The Swiss Simon André Tissot, reported in his Traité des Nerves et de leurs Maladies (1778) (written 10 years earlier): ‘Sydenham… was the first to remark on the protean character of the nervous disease and to suggest that its symptoms might result from a disturbance in nervous function’.

The physiopathological view, the other dominant trend in nineteenth-century scientificonatural medicine, developed as a modification of the anatomoclinical view which must be considered as the very foundation of the new medicine. Its novelty was to emphasize the ‘functional’, which had been neglected by the great French writers and their followers, and to study objectively clinical and pathological dysfunctions. Laín Entralgo has carried out a masterly study of the group of German authors (Wunderlich, Griesinger, Frerichs and Traube) who occupied themselves with the notion of dysfunction. They presided over the modification of the anatomoclinical view under the influence of dynamic and idealist views received from an earlier period of German medicine. The dynamic processes of old, rid of all speculative elements, adapted themselves to the new view: Naturphilosophie became Naturwissenschaft.

The preponderance of the German school should not conceal the fact that the French and the British also sponsored the physiopathological view. In the Paris of the early nineteenth century the only view that kept the notion of the ‘functional’ alive was the ‘heterodox’ doctrine of Broussais. The so-called ‘Physiological medicine’, although occasionally exaggerated, showed a commendable insistence on physiopathology. Its early demise did not prevent ‘Médecine physiologique’ from influencing both the orthodox French anatomoclinical view and the British physiopathological school. However the main origin of the latter must still be sought in the influential views of John Hunter who interested himself both in the experimental analysis of function and in its post-mortem concomitants.

Although the history of the concept of neurosis during the twentieth century can be said to be a direct continuation of the views of Charcot and Freud, it has created severe difficulties amongst historians; this problematic character partially results from the fact that it has been used as a battle ground by schools of thought such as the scientific-natural method, psychoanalysis and psychosomatic pathology. Over the years this has given rise to numerous attempts at reformulating the concept of neurosis, criticising its foundations and even eliminating it altogether.

Most authors agree on the usefulness of analysing the concept historically. In a meeting held in 1925, dedicated to a ‘Revision of the Problem of the Neurosis’, Oswald Bumke, a representative of the reaction of German academic psychiatry against psychoanalysis, stated:

Unfortunately Bumke did not undertake nor encourage anyone else to do any historical research. He simply iterated few commonplaces about the evolution of the concept and used them to support his personal views.

The anatomoclinical view provided the earliest conceptual foundation of scientificonatural medicine during the nineteenth century. This achievement of the anatomoclinicians Laín Entralgo has called the ‘copernican revolution operated by the concept of anatomopathological lesion’ for the anatomical lesion, until then less important than the symptom, became the very basis of medicine.

A confrontation therefore was inevitable between the new view, based on localization and a reduction to the anatomical level, and the concept of neurosis, related since its inception to general diseases and interpreted physiologically. This confrontation will be explored first in the work of Pinel who presided over the transition between the Enlightenment and the new views; then in relation to the period during which efforts were made to jettison the concept of neurosis culminating with Georget's fundamental revision; finally its evolution will be traced during the zenith of the anatomoclinical view, between Georget and Charcot.

Pinel's work as the starting point of the anatomoclinical view of the neuroses

Paris was the indisputable capital of anatomoclinical medicine during the early nineteenth century. The French revolution and the ensuing sociopolitical climate had done away with all existing medical institutions and brought into being new ones free from the burden of tradition. For about twenty years Philippe Pinel (1745–1826), imbued by the ideal of a new medicine, presided over the transformation. Remembered as one of the founders of psychiatry, it is less known that he also forged the link between the Enlightenment and anatomoclinical pathology.