The Oxford Handbook of the History of Medicine (Oxford Handbooks) 9780199546497, 0199546495

The Oxford Handbook of the History of Medicine celebrates the richness and variety of medical history around the world.

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The Oxford Handbook of the History of Medicine (Oxford Handbooks)
 9780199546497, 0199546495

Table of contents :
Cover
Contents
List of Illustrations and Tables
List of Contributors
1. Introduction
PART I: PERIODS
2. Medicine and Health in the Graeco-Roman World
3. Medieval Medicine
4. Early Modern Medicine
5. Health and Medicine in the Enlightenment
6. Medicine and Modernity
7. Contemporary History of Medicine and Health
PART II: PLACES AND TRADITIONS
8. Global and Local Histories of Medicine: Interpretative Challenges and Future Possibilities
9. Chinese Medicine
10. Medicine in Islam and Islamic Medicine
11. Medicine in Western Europe
12. History of Medicine in Eastern Europe, Including Russia
13. Science and Medicine in the United States of America
14. Public Health and Medicine in Latin America
15. History of Medicine in Sub-Saharan Africa
16. Medicine and Colonialism in South Asia since 1500
17. History of Medicine in Australia and New Zealand
PART III: THEMES AND METHODS
18. Childhood and Adolescence
19. Medicine and Old Age
20. Death
21. Historical Demography and Epidemiology: The Meta-Narrative Challenge
22. Chronic Illness and Disease History
23. Public Health
24. The Political Economy of Health Care in the Nineteenth and Twentieth Centuries
25. Health, Work, and Environment: A Hippocratic Turn in Medical History
26. History of Science and Medicine
27. Women, Health, and Medicine
28. Health and Sexuality
29. Medicine and the Mind
30. Medical Ethics and the Law
31. Medicine and Species: One Medicine, One History?
32. Histories of Heterodoxy
33. Oral Testimony and the History of Medicine
34. Medical Film and Television: An Alternative Path to the Cultures of Biomedicine
Index
A
B
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D
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F
G
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I
J
K
L
M
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Citation preview

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

411

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.



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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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

m edieva l m edici n e p eregrine horden

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,

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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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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

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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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39.

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.

Select Bibliography Bos, G., Ibn al-Jazzār on Sexual Diseases and Their Treatment: A Critical Edition of Zâd al-musāfir wa-qut al-Ḥād. ir (London: Kegan Paul, 1997). —— — , Ibn al-Jazzār on Fevers: A Critical Edition of Zâd al-musāfir wa-qut al-Ḥâd. ir (London: Kegan Paul, 2000). Burnett, C., and D. Jacquart (eds), Constantine the African and ‘Alī ibn al-‘Abbās al-Magūsī The Pantegni and Related Texts (Leiden: Brill, 1994). Conrad, L. I., ‘Tâ‘ûn and wabâ’: Conceptions of Plague and Pestilence in Early Islam’, Journal of the Economic and Social History of the Orient 25 (1982), 268–307. Crussol des Epesse, B. T. de, Discours sur l’oeil d’Esmā’il-e Gorgāni (Tehran: Presses universitaires d’Iran; Institut Français de Recherche en Iran, 1998). Dols, M. D., ‘The Origins of the Islamic Hospital: Myth and Reality’, Bulletin of the History of Medicine 61 (1987), 367–90.

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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.

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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

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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)