History of Medicine: Health, Medicine and Disease in the Eighteenth Century

Abstract

This article surveys anglophone scholarship in the history of medicine over the past decade or so. It selectively identifies and critically evaluates key themes and trends in the field. It discusses the emergence of the discipline from a period of directional crisis to more recent emphasis on a pluralistic and ‘bigger-picture’ agenda, on comparative, cross-disciplinary and multicultural approaches, and on the reorientation and (putative) broadening out of medical history towards wider public engagement and closer interface with medical humanities.

In the past decade the intellectual breadth, status and coherence of the history of medicine have undergone significant re-evaluation. This essay will give an account of this reassessment, providing a necessarily partial survey of the most significant contributions to the field, though focusing only on recent scholarship published in English. The millennium began with scholars more appreciative of the flaws in influential previous approaches, including retrodiagnostic-inspired medical history, and reassessing the virtues of others, including social constructionist accounts.¹ Recognising the achievements of the social history of medicine, and generally gratified that over-progressive, clinically construed historiographies have been superseded, some scholars have nonetheless criticised the ‘social’ turn of medical history for sidelining medico-scientific theory/ideas. Researchers have remained rather at odds, moreover, over what the history of medicine ought to be. For some, the field is ‘divided almost irreconcilably between intellectual, economic, social, and cultural historians of medicine’.² While some preach eschewal of the reductive sociological excesses of constructivism, others’ suggestions for overcoming the field’s apparent rifts, including espousing linguistic engagement with the rhetoric of illness/healing, have received uneven endorsement. Likewise, reassertions of the centrality of social constructivist methodologies have mostly met with unreceptive (or divergent) responses.³

Controversial evaluations of over-specialised tendencies in the history of medicine and its allegedly antipathetic engagement with other disciplinary areas have also emerged with particular vigour. Doubts redounding as to the discipline’s engagement with big ‘impact’ questions and its ‘relevance’ to contemporary health/scientific concerns implied some sort of directional ‘crisis’.⁴ In Britain the melodramatically inclined pronounced the once ‘new’ social history of medicine to be defunct, mired in a sterile, insular set of discourses.⁵ Conspicuous dents to institutional confidence culminated with the near sinking of the field’s academic flagship, University College London’s Wellcome Trust-funded centre. This also precipitated a significant lurch in the Trust’s funding programmes for the history of medicine. Reconfigured in 2009-10 in a broader format as a ‘medical history and humanities’ stream, the effects of this repositioning will not fully emerge for some time. While some scholars express anxieties about the potential dilution of historicised meaning and presentist agenda-setting, others are prepared to embrace the history of medicine as a more inclusive, publicly engaged and ‘bigger-picture’ undertaking. Nor was this seeming ‘crisis’ limited to Anglo-American contexts, for apparent disciplinary decline had also aroused concern among Continental medical historians.⁶ Some appealed for further development of a ‘new cultural history of medicine’, more committed to inter/cross-disciplinarity, less animated by the political axe-grinding and critiques of medical power/oppression that, post-1960, preoccupied many academic studies of medicine.⁷ Conversely, prominent modernists espouse a history of medicine more concerned to engage in dialogue with social and health policymakers, or with contextualised, critically reflexive applications of the ‘lessons’ of history to the biological and human sciences, especially for the purpose of medical education.⁸ Rather than disciplinary strife, many would agree with middle-ground advocacy of a warmer climate of critical appreciation for intellectual and disciplinary pluralism, short of any implied eschewal of the centrality of methodological debates.⁹ Most scholars would also endorse best-practice examples of wider communication and advocate broader (meaningful) public engagement. Some have asserted the conceptual and methodological significance and coherence (more than mere relevance) of a genuinely historicised medical humanities programme.¹⁰ But scholars have differed over how far the history of medicine should assert or lose its critical independence and be relocated as an allied or sub-discipline of medical humanities.

Some may contend that the key concerns of medical historians have continued to gravitate around traditional themes – professionalisation, medical personnel, diseases and mortality, medical education, medical knowledge and technologies, therapeutic theory and practice, and institutional medicine. While neglected areas of scientific theory and praxis, such as veterinary and dental medicine, have attracted more serious scholarly attention, they remain comparatively under-explored.¹¹ In terms of medical education, medical/scientific theory and their relation to medical praxis, recent authoritative national/continental studies ranging across Enlightenment Europe have consistently and predictably outweighed comparative and supra-national/non-Western coverage. However, this would pay insufficient regard to the continued expansion of interdisciplinary approaches, some combining traditional history of medicine/science with literary studies approaches, others melding history of ideas with linguistic, epistemological and sociology of knowledge approaches.¹² This would also disregard significant signs of increased commitment to cross-national and cross-cultural comparison in recent medical histories.¹³

Deeper societal appreciation of the interests of globalism and diversity has certainly given rise to a less Western-centric, geographically broader history of medicine, more appreciative of interchanges, of pluralities and of differing racial and cultural composition in differing health contexts. Comparative dimensions have also taken a more prominent place in academics’ endeavours and grant-awarding bodies’ agendas, even if scholars still bemoan the relative paucity of comparative medical history.¹⁴ Although tending towards a post-1800 focus, scholarly research on Latin American, Asian, African and Australasian health, disease and medicine has displayed tremendous vigour and freshness of perspectives.¹⁵ Particularly notable are Pratik Chakrabarti’s publications tracing the negotiated processes of medicoscientific and medico-cultural knowledge exchanges between indigenous Indians and European colonisers and surveying colonial medico-material markets, medical practice and medical practitioners’ identities in south Asia and the Caribbean.¹⁶ Other major recent studies of colonial medico-scientific contexts have included Londa Schiebinger’s survey of the myriad pathways of botanical beliefs/knowledge, challenging simplistic diffusion of knowledge models.¹⁷ Meanwhile, Linda L. Barnes’s and Volker Scheid’s medical anthropological/ethnographic longue-durée surveys of Chinese medical traditions and Larissa N. Heinrich’s interdisciplinary analysis of the cross-transmission of pathological images of Chinese patients rank among a range of distinguished national and local studies of oriental medicine.¹⁸

While institutional and biographical history has somewhat fallen out of fashion since the early 1990s, empirical regional and national surveys of medical institutions, practitioners, societies and publications continue to be medical historians’ bread and butter. European institutional studies have distinguished themselves for their emphasis on understanding hospitals in relation to both state bureaucracies and the wider public, and to local, national and supra-national political and socio-economic networks. They have also been valuable in highlighting broader notions of medicalisation, linked to shifting conceptualisations of sickness and poverty, and the negotiation of hospital care by its recipients.¹⁹ Noteworthy among recent institutional surveys covering our period is Guenter B. Risse’s extensive study of British and European hospitals, while national and regional hospital histories have also been very well served.²⁰ Some studies spotlight the social, epidemiological and mortality impact of medical institutions; others concentrate on access to, and boundaries of, institutional charitable relief and the economics of hospital provision.²¹ There have been some particularly accomplished architectural, landscape and spatial analyses of institutions.²² Some studies have trodden fresher ground, as with recent work on hospital visiting and on medicine and the public sphere.²³ While, with a few exceptions, we still lack surveys of certain kinds of institutions, such as eighteenth-century infirmaries and dispensaries, other research has showcased the benefits of exploring health and medicine far beyond institutional settings.²⁴ One of the key criteria in differentiating the resonance of such work remains the extent to which it provides a broader intellectual, theoretical and methodological framework for knitting institutions to their wider contexts.

Fastidiously researched but relatively traditional, evolutionary studies of medical elites have continued to appear, emphasising pre-scientific medicine or the making of ‘modern’ medical science and technology.²⁵ Yet for some time histories of medical professions/occupations have accorded more democratising attention to healers as well as practitioners. We are now much better informed about the socio-professional milieu not only of doctors, surgeons, apothecaries and surgeon-apothecaries but also of midwives/ female healers, druggists, ‘quacks’ and other irregular practitioners.²⁶ Earlier scholarly laments for the relative absence of scholarship on surgeons/surgery and apothecaries/pharmacy have been partially soothed by recent broad-based surveys and by some sophisticated accounts of individual practitioners.²⁷ Scholars now stress the fluidity, eclecticism and exchanges rather than the dichotomies between elite/regular and popular/irregular medical culture/practitioners, and the processes of confidence-building, or commercial interaction and socio-political power-broking.²⁸ Work on medical networks and identities emphasises the advantages of exploiting a broader range of source materials relating to medical practice and professional formation.²⁹ The history of eighteenth-century anatomy has continued to generate excellent new scholarship, as has the relationship between religion and medical enlightenment, although the interface between medicine, religion and suffering is a relatively novel feature of recent early modern scholarship.³⁰ Military and naval medicine has attracted more concerted analysis, ranging from the careers and practice of army/naval practitioners and nutrition and food/drink supply to the health and mortality of seamen, soldiers and slaves.³¹

The history of diseases has similarly remained centre-frame. We have profited from wide-ranging analyses of epidemics, pandemics and fevers, of the social and state responses they generated and of the interface between medical and cultural/literary representations. Debates continue to rage over the nature, scope and balance of factors – epidemiological, socio-economic, environmental and medical – shaping demographic changes. The latest work has addressed not merely older themes, such as diseases’ impact on societies/ populations and the limits/success of human counter-measures, but also how sufferers survived and how diseases and their treatments were avoided/ accepted and responded to by sufferers.³² Authoritative surveys combining exhaustive mortality/demographic and epidemiological approaches with ambitious comparative statistically driven perspectives may seem rather dry to readers more sympathetic to cultural discourse analysis, although patently divergent approaches often benefit from inter-dialogue.³³ The latest accounts of colonial diseases have both elucidated and fixated on knowledge transmission and exchange between centres and peripheries. Plague(s) and smallpox have continued to generate much attention and contention, including Elizabeth A. Fenn’s seminal survey of the impact of the late eighteenth-century smallpox epidemic on white colonial American society, but also on indigenous and slave populations from Mexico to Canada.³⁴ Accessible guidance has been provided by some authoritative pathographies of diseases.³⁵ Yet while the post-industrial era continues to be well served in recent scholarship, research on the epidemiology, nosology and cultural meaning of disease and illness in the eighteenth century has been comparatively modest. Venereal diseases have attracted disproportionately large-scale attention, with some studies distinguished for integrating children’s health and others marred by (excessive) focus on medical markets, morality and elite actors.³⁶ Some scholars have provided meticulously researched correctives to retro-readings of diseases back from modern concepts but have also been critiqued for their partialities, neglecting issues of race, gender and sexuality.³⁷ Other work addresses mythologies and blame cultures around diseases’ origins or makes a virtue of demographic and narrative sources to clarify disease–life-cycle impact and doctors’ limited roles in sufferers’ lives.³⁸ Kevin P. Sienna’s superb study of London hospitals’ ‘Foul Wards’ focuses on poxed bodies and the experiential burdens of poor sufferers, somewhat offsetting previous scholarly stress on the judgemental tenor of institutional regimes.³⁹

More attention to chronic and less well-researched fashionable/ unfashionable diseases has also been a welcome development.⁴⁰ Medical, cultural, literary and art historians have newly colonised the study of a range of neglected bodily conditions. Research on menstruation has challenged the previous fixation on pathology and treatment, addressing a range of issues from attitudes regarding sexual difference to popular beliefs/knowledge and regulation.⁴¹ The history of corpulence, or obesity, which, as Sander L. Gilman highlights, was historically defined as a state or phenomenological entity rather than a disease, has also generated considerable interest.⁴² Recent multifaceted studies provide insightful inter-linkages of medico-physiological discourse on digestion, excretion, fat and the stomach and its disorders with philosophical, literary and (elite) narratives on selfhood, hedonism the body and the mind/imagination.⁴³ The resonance of some work in this field has been restricted by its single-practice focus (however well contextualised) or, in contrast, by desultory, question-begging leaps across huge chronological and geographical terrain.⁴⁴ Other research is, moreover, gradually embracing scholarly espousal of thoroughgoing disciplinary linkage between environmental history and the history of health and diseases.⁴⁵

Despite long-standing calls for research on quotidian maladies such as dyspepsia and bilious disorders, the profoundly domestic context for the experience and healing of mundane ailments, from headache to rheumatism, remains neglected. Nonetheless, new scholarship on domestic medicine, medically mediated cookery, dietaries and cosmetics, medical receipt/commonplace books and illness cultures has begun to bridge the research gap. Recent published and unpublished work manifests an enduring concern with offsetting official medicine sources and perspectives, privileging popular sickness cultures/traditions, explicatory frameworks and self-help.⁴⁶ However, historians have had limited success mapping patterns of choice and usage across different regions/classes or between rural and urban settings over time or, more precisely, delineating how and when domestic and herbal cures were supplanted by patent, over-the-counter and chemical remedies. For at least two decades scholars have likewise been shifting attention towards historicised concepts of health, longevity, well-being and preventive medicine as well as sickness/disease.⁴⁷ Similarly, new studies of popular and indigenous healing and healers have paid more attention to religio-supernatural, magical and herbal beliefs and practices.⁴⁸ Meanwhile, debates remain vigorous as to the extent to which diffusion of medical knowledge transcended the boundaries of ‘popular’ medical cultures.⁴⁹

While earlier cultish enthusiasm for the history of the body has somewhat paled, scholars have continued to produce important contributions on this theme. The millennium began with scholarship reflecting the vibrancy of cultural and disability studies approaches to eighteenth-century bodies, selfhood and identities. Roy Porter’s magisterial studies continue (posthumously) to enrich our understanding, ranging insightfully over the prevailing meanings attached to bodily representations of medical practitioners, diseases and death, and how selfhood was expressed and culturally embedded via corporeally centred ideas and practices.⁵⁰ Some contributions traverse relatively well-trodden ground, such as the anatomised, dissected and tortured body and the factors mediating eighteenth-century responses to deformities, defects and monstrosities, as well as definitional anomalies and epistemological conflicts.⁵¹ Other scholars, however, chart newer territory, including medical constructions of masculine, pauper and literary bodies, or of particular bodily parts, protuberances, fluids and excrescences.⁵² Studies have ranged from literary–cultural and semiotic surveys of surgical patients’ bumps and wheals, and the socio-moral and psychosomatic meanings of hands and blood, to mental and physiological pathologies associated with reading.⁵³ Bizarrely neglected as a major subject of historical enquiry, despite Barbara Duden’s pioneering work, the history of the skin is only slowly receiving more concerted scholarly attention.⁵⁴

Earlier work on the medical marketplace and its practitioners in early modern Europe was perhaps more concerned with a supply model than with the interests, motivations and choices of clients/patients – the actual purchasers as well as the providers of services. Historians have long appreciated a broader agenda to comprehend popular medical cultures/belief systems, as well as established corporate and institutional medical systems.⁵⁵ Recently scholars have not only widened knowledge of practitioners’ selling strategies, reputations and representations but also emphasised the complex role of patient demand and the need for clearer, product-based and geographical delineation of specific medical markets.⁵⁶ Trenchant querying of imprecision in concepts of the medical marketplace has been accompanied by greater stress on economic, social and religio-moral agencies/factors behind the emerging demand for and prominence of particular medical commodities/services.⁵⁷ Important shifts and variations in local markets have been traced, legal contexts for negotiating patients’ contractual rights emphasised and notions of the passive or autonomous consumer challenged.⁵⁸

Many historians have extensively utilised neglected patient records and narrative sources significantly to adjust existing top-down models of medicine and disease/illness in the eighteenth century. If coverage of elite patient perspectives has continued to dominate, there have been numerous deeper explorations of the wider social negotiation of medical care, and of patient participation and expectations, in regard to health/medicine.⁵⁹ Nonetheless, some have persuasively argued that the patient view remains an elusive, theoretically and methodologically underdeveloped field.⁶⁰

Belying my earlier emphasis on continuities in new-millennium medical histories, there have also been some important thematic and approach shifts in the field. Fundamental recent work on the history of welfare and medicine has not only placed regional variations in sharper focus but also provided a firmer basis for international comparison of welfare systems and extensive integration of the health/illness perspectives of the poor.⁶¹ Reflecting demographic, political, socio-economic and socio-cultural trends attuning health priorities in contemporary Western societies, deepening academic interest in health and medicine at either end of the life cycle has also been prominent. It is no longer possible to argue that the healthcare, interests and remedial treatment of children were not important features of early modern medicine and society.⁶² We now know much more about the health and welfare of children in early modern institutions, about how children’s minds, bodies and constitutions were conceptualised, about why treatments were adjusted and made specific for children, about how children experienced illness, pain and discomfort, and about how doctors and wider society viewed such experiences. Scholars adopting demographic, socio-economic and welfare history approaches (such as Pat Thane), or intellectual history approaches (Daniel Schäfer) have significantly supplied gaps in our knowledge of early modern medical conceptions of and provision for the elderly.⁶³

Two particular areas stand out as currently attracting a great deal of scholarly attention: the senses and the emotions. Important expeditions into this terrain have included conceptual, longue-durée analyses of the heart and nuanced surveys of articulations of the affections, appetites, passions and sensibilities.⁶⁴ The best of this work succeeds in integrating the senses, and more particularly the emotions, within prevailing understandings of the impact of individual/collective health identities, medical professionalisation, treatment and institutionalisation.⁶⁵ However, the debatable potential for any novel historiography of the senses and emotions fundamentally to elucidate ideas/practices demarcating medicine, and notions of the normal and pathological, has yet to be realised. Meanwhile, the broadening out of historical examinations of pain may be contrasted with the subject’s comparative neglect for the eighteenth century, despite recent studies’ partial corrective for this hiatus.⁶⁶

This brief survey of recent work in the history of health/illness and medicine is a subjectively selective one of a vast field. I have sought not to provide special pleading for particular approaches but rather to outline some important themes and novel developments in scholarship, as well as areas of consensus and debate. My focus has been on anglophone research, with much more limited reference to coverage of medicine in Europe, Asia, Africa, Australasia and the Americas. Space has dictated that significant cognate areas have been omitted: in particular, the interfaces between the history of medicine and the history of science and technology, as well as histories of psychiatry, madness, disability and sexuality. Despite this, and irrespective of any putative disciplinary ‘crisis’, it is clear how appreciably the field has broadened out in the past decade, to embrace less Euro-centric and more cross-cultural, comparative approaches, as well as significantly to traverse disciplinary boundaries. The current richness of eighteenth-century studies of health and medicine is already rendering medical history a misleading misnomer; scholars appear keener than ever to embrace a greater variety of theoretical perspectives and methodological approaches. On the other hand, the eighteenth century remains under-represented in funding terms (notably less successful in the past decade’s audit of Wellcome Trust awards) and is too frequently sidelined in edited collections and synthesising studies that all too often leap from pre-1700 to post-industrial and post-colonial studies.

Biography

JONATHAN ANDREWS is a Reader in the History of Psychiatry at Newcastle University. His research interests reside primarily in the history of mental illness, learning disabilities and psychiatry in Britain from roughly 1600 to 1914. He has published three monographs in the field: The History of Bethlem (written with Roy Porter et al., 1997) and, more recently (with Andy Scull) Undertaker of the Mind (2001) and Customers and Patrons of the Mad Trade (2003). He is on the editorial board of History of Psychiatry and of the Journal of Forensic Psychiatry.