Medical Nemesis
4
The Invention and
Elimination of Disease
The French Revolution gave birth to two great myths: one, that
physicians could replace the clergy; the other, that with political
change society would return to a state of original health.1 Sickness
became a public affair. In the name of progress, it has now ceased to
be the concern of those who are ill.2
For several
months in 1792, the National Assembly in Paris tried to decide how to
replace those physicians who profited from care of the sick with a
therapeutic bureaucracy designed to manage an evil that was destined to
disappear with the advent of equality, freedom, and fraternity. The new
priesthood was to be financed by funds expropriated from the Church. It
was to guide the nation in a militant conversion to healthy living
which would make medical sick-care less necessary. Each family would
again be able to take care of its members, and each village to provide
for the sick who were without relatives. A national health service
would be in charge of health care and would supervise the enactment of
dietary laws and of statutes compelling citizens to use their new
freedoms for frugal living and wholesome pleasures. Medical officers
would supervise the compliance of the citizenry, and medical
magistrates would preside over health tribunals to guard against
charlatans and exploiters.
Even more radical were
the proposals from a subcommittee for the elimination of beggary. In
content and style they are similar to Red Guard and Black Panther
manifestos demanding that control over health be returned to the
people. Primary care, it was asserted, belongs only to the
neighborhood. Public funds for sick-care are best used to supplement
the income of the afflicted. If hospitals are needed, they should be
specialized: for the aged, the incurable, the mad, or foundlings.
Sickness is a symptom of political corruption and will be eliminated
when the government is cleaned up.
The
identification of hospitals with pestholes was current and easy to
explain. They had appeared under Christian auspices in late antiquity
as dormitories for travelers, vagrants, and derelicts. Physicians began
to visit hospitals regularly at the time of the crusades, following the
example of the Arabs.3 During the late Middle Ages, as charitable
institutions for the custody of the destitute, they became part and
parcel of urban architecture.4 Until the late eighteenth century the
trip to the hospital was taken, typically, with no hope of return.5
Nobody went to a hospital to restore his health. The sick, the mad, the
crippled, epileptics, incurables, foundlings, and recent amputees of
all ages and both sexes were jumbled together;6 amputations were
performed in the corridors between the beds. Inmates were given some
food, chaplains and pious lay folk came to offer consolation, and
doctors made charity visits. The cost of remedies made up less than 3
percent of the meager budget. More than half went for the hospital
soup; the nuns could get along on a pittance. Like prisons, hospitals
were considered a last resort;7 nobody thought of them as tools for
administering therapy to improve the inmates.8
Logically, some extremists went beyond the recommendations made by the
committee on beggary. Some demanded the outright abolition of all
hospitals, saying that they "are inevitably places for the aggregation
of the sick and breed misery while they stigmatize the patient. If a
society continues to need hospitals, this is a sign that its revolution
has failed."9
A misunderstanding of Rousseau
vibrates in this desire to restore sickness to its "natural state,"10
to bring society back to "wild sickness," which is self-limiting and
can be borne with virtue and style and cared for in the homes of the
poor, just as previously the sicknesses of the rich had been taken care
of. Sickness becomes complex, untreatable, and unbearable only when
exploitation breaks up the family,11 and it becomes malignant and
demeaning only with the advent of urbanization and civilization. For
Rousseau's followers the sickness seen in hospitals was man-made, like
all forms of social injustice, and it thrived among the self-indulgent
and those whom they had impoverished. "In the hospital, sickness is
totally corrupted; it turns into 'prison fever' characterized by
spasms, fever, indigestion, pale urine, depressed respiration, and
ultimately leads to death: if not on the eighth or eleventh day, then
on the thirteenth." 12 It is this kind of language that made medicine
first become a political issue. The plans to engineer a society into
health began with the call for a social reconstruction that would
eliminate the ills of civilization. What Dubos has called "the mirage
of health" began as a political program.
In the
public rhetoric of the 1790s, the idea of using biomedical
interventions on people or on their environment was totally absent.
Only with the Restoration was the task of eliminating sickness turned
over to the medical profession. After the Congress of Vienna, hospitals
proliferated and medical schools boomed.13 So did the discovery of
diseases. Illness was still primarily nontechnical. In 1770, general
practice knew of little besides the plague and the pox,14 but by 1860
even the ordinary citizen recognized the medical names of a dozen
diseases. The sudden emergence of the doctor as savior and miracle
worker was due not to the proven efficacy of new techniques but to the
need for a magical ritual that would lend credibility to a pursuit at
which a political revolution had failed. If "sickness" and "health"
were to lay claim to public resources, then these concepts had to be
made operational. Ailments had to be turned into objective diseases
that infested mankind, could be transplanted and cultivated in the
laboratory, and could be fitted into wards, records, budgets, and
museums. Disease was thus accommodated to administrative management;
one branch of the elite was entrusted by the dominant class with
autonomy in its control and elimination. The object of medical
treatment was defined by a new, though submerged, political ideology
and acquired the status of an entity that existed quite separately from
both doctor and patient.15
We tend to forget how
recently disease entities were born. In the mid-nineteenth century, a
saying attributed to Hippocrates was still quoted with approval: "You
can discover no weight, no form nor calculation to which to refer your
judgment of health and sickness. In the medical arts there exists no
certainty except in the physician's senses." Sickness was still
personal suffering in the mirror of the doctor's vision.16 The
transformation of this medical portrait into a clinical entity
represents an event in medicine that corresponds to the achievement of
Copernicus in astronomy: man was catapulted and estranged from the
center of his universe. Job became Prometheus.
The
hope of bringing to medicine the elegance that Copernicus had given
astronomy dates from the time of Galileo. Descartes traced the
coordinates for the implementation of the project. His description
effectively turned the human body into clockworks and placed a new
distance, not only between soul and body, but also between the
patient's complaint and the physician's eye. Within this mechanized
framework, pain turned into a red light and sickness into mechanical
trouble. A taxonomy of diseases became possible. As minerals and plants
could be classified, so diseases could be isolated and categorized by
the doctor-taxonomist. The logical framework for a new purpose in
medicine had been laid. Instead of suffering man, sickness was placed
in the center of the medical system and could be subjected to (a)
operational verification by measurement, (b) clinical study and
experiment, and (c) evaluation according to engineering norms.
Antiquity knew no yardstick for disease.17 Galileo's contemporaries
were the first to try to apply measurement to the sick, but with little
success. Since Galen had taught that urine was secreted directly from
the vena cava and that its composition was a direct indication of the
nature of the blood, doctors had tasted and smelled urine and assayed
it by the light of sun and moon. After the sixteenth century,
alchemists had learned to measure specific gravity with considerable
precision, and they subjected the urine of the sick to their methods.
Dozens of distinct and differing meanings were ascribed to changes in
the specific gravity of urine. With this first measurement, doctors
began to read diagnostic and curative meaning into any new measurement
they learned to perform.18
The use of physical
measurements prepared for a belief in the real existence of diseases
and their ontological autonomy from the perception of doctor and
patient. The use of statistics underpinned this belief. It "showed"
that diseases were present in the environment and could invade and
infect people. The first clinical tests using statistics, which were
performed in the United States in 1721 and published in London in 1722,
provided hard data indicating that smallpox was threatening
Massachusetts and that people who had been inoculated were protected
against its attacks. They were conducted by Dr. Cotton Mather, who is
better known for his inquisitorial fury at the time of the Salem witch
trials than for his spirited defense of smallpox prevention.19
During the seventeenth and eighteenth centuries, doctors who applied
measurements to sick people were liable to be considered quacks by
their colleagues. During the French Revolution, English doctors still
looked askance at clinical thermometry. Together with the routine
taking of the pulse, it became accepted clinical practice only around
1845, nearly thirty years after the stethoscope was first used by
Laënnec.
As the doctor's interest shifted from the
sick to sickness, the hospital became a museum of disease. The wards
were full of indigent people who offered their bodies as exhibits to
any physician willing to treat them.20 The realization that the
hospital was the logical place to study and compare "cases" developed
towards the end of the eighteenth century. Doctors visited hospitals
where all kinds of sick people were mingled, and trained themselves to
pick out several "cases" of the same disease. They developed "bedside
vision," or a clinical eye. During the first decades of the nineteenth
century, the medical attitude towards hospitals went through a further
development. Until then, new doctors had been trained mostly by
lectures, demonstrations, and disputations. Now the "bedside" became
the clinic, the place where future doctors were trained to see and
recognize diseases.21 The clinical approach to sickness gave birth to a
new language which spoke about diseases at the bedside, and to a
hospital reorganized and classified by disease for the exhibition of
ailments to students.22
The hospital, which at the
very beginning of the nineteenth century had become a place for
diagnosis, was now turned into a place for teaching. Soon it would
become a laboratory for experimenting with treatments, and towards the
turn of the century a place concerned with therapy. Today the pesthouse
has been transformed into a compartmentalized repair shop. All this
happened in stages. During the nineteenth century, the clinic became
the place where disease carriers were assembled, diseases were
identified, and a census of diseases was kept. Medical perception of
reality became hospital-based much earlier than medical practice. The
specialized hospital demanded by the French Revolutionaries for the
sake of the patient became a reality because doctors needed to classify
sickness. During the entire nineteenth century, pathology remained
overwhelmingly the classification of anatomical anomalies. Only towards
the end of the century did the pupils of Claude Bernard also begin to
label and catalogue the pathology of functions.23 Like sickness, health
acquired a clinical status, becoming the absence of clinical symptoms,
and clinical standards of normality became associated with well-being.24
Disease could never have been associated with abnormality if the value
of universal standards had not come to be recognized in one field after
another over a period of two hundred years. In 1635, at the behest of
Cardinal Richelieu, the king of France formed an academy of the forty
supposedly most distinguished men of French letters for the purpose of
protecting and perfecting the French language. In fact, they imposed
the language of the rising bourgeoisie which was also gaining control
over the expanding tools of production. The language of the new class
of capitalist producers became normative for all classes. State
authority had expanded beyond statute law to regulate means of
expression. Citizens learned to recognize the normative power of an
elite in areas left untouched by the canons of the Church and the civil
and penal codes of the state. Offenses against the codified laws of
French grammar now carried their own sanctions; they put the speaker in
his place—that is, deprived him of the privileges of class and
profession. Bad French was that which fell below academic standards, as
bad health would soon be that which was not up to the clinical norm.
In Latin norma means "square," the carpenter's square. Until the 1830s
the English word "normal" meant standing at a right angle to the
ground. During the 1840s it came to designate conformity to a common
type. In the 1880s, in America, it came to mean the usual state or
condition not only of things but also of people. In France, the word
was transposed from geometry to society—école normale designated a
school at which teachers for the Empire were trained—and was first
given a medical connotation around 1840 by Auguste Comte. He expressed
his hope that once the laws relative to the normal state of the
organism were known, it would be possible to engage in the study of
comparative pathology.25
During the last decade of
the nineteenth century, the norms and standards of the hospital became
fundamental criteria for diagnosis and therapy. For this to happen, it
was not necessary that all abnormal features be considered
pathological; it was sufficient that disease as deviance from a
clinical standard make medical intervention legitimate by providing an
orientation for therapy.26
The age of hospital
medicine, which from rise to fall lasted no more than a century and a
half, is coming to an end.27 Clinical measurement has been diffused
throughout society. Society has become a clinic, and all citizens have
become patients whose blood pressure is constantly being watched and
regulated to fall "within" normal limits. The acute problems of
manpower, money, access, and control that beset hospitals everywhere
can be interpreted as symptoms of a new crisis in the concept of
disease. This is a true crisis because it admits.of two opposing
solutions, both of which make present hospitals obsolete. The first
solution is a further sickening medicalization of health care,
expanding still further the clinical control of the medical profession
over the ambulatory population. The second is a critical,
scientifically sound demedicalization of the concept of disease.
Medical epistemology is much more important for the healthy solution of
this crisis than either medical biology or medical technology. Such an
epistemology will have to clarify the logical status and the social
nature of diagnosis and therapy, primarily in physical—as opposed to
mental—sickness. All disease is a socially created reality. Its meaning
and the response it has evoked have a history.28 The study of this
history will make us understand the degree to which we are prisoners of
the medical ideology in which we were brought up.
A
number of authors have recently tried to debunk the status of mental
deviance as a "disease."29 Paradoxically, they have rendered it more
and not less difficult to raise the same kind of question about disease
in general. Leifer, Goffman, Szasz, Laing, and others are all
interested in the political genesis of mental illness and its use for
political purposes.30 In order to make their point, they all contrast
"unreal" mental with "real" physical disease: in their view the
language of natural science, now applied to all conditions that are
studied by physicians, really fits physical sickness only. Physical
sickness is confined to the body, and it lies in an anatomical,
physiological, and genetic context. The "real" existence of these
conditions can be confirmed by measurement and experiment, without any
reference to a value-system. None of this applies to mental sickness:
its status as a "sickness" depends entirely on psychiatric judgment.
The psychiatrist acts as the agent of a social, ethical, and political
milieu. Measurements and experiments on these "mental" conditions can
be conducted only within an ideological framework which derives its
consistency from the general social prejudice of the psychiatrist. The
prevalence of sickness is blamed on life in an alienated society, but
while political reconstruction might eliminate much psychic sickness,
it would merely provide better and more equitable technical treatment
for those who are physically ill.
This
antipsychiatric stance, which legitimizes the non-political status of
physical disease by denying to mental deviance the character of
disease, is a minority position in the West, although it seems to be
close to an official doctrine in modern China, where mental illness is
perceived as a political problem. Maoist politicians are placed in
charge of psychotic deviants. Bermann31 reports that the Chinese object
to the revisionist Russian practice of depoliticizing the deviance of
class enemies by locking them into hospitals and treating them as if
they had a sickness analogous to an infection. They pretend that only
the opposite approach can give results: the intensive political
re-education of people who are now, perhaps unconsciously, class
enemies. Their self-criticism will make them politically active and
thus healthy. Here again, the insistence on the primarily nonclinical
nature of mental deviance reinforces the belief that another kind of
sickness is a material entity.32
Advanced
industrial societies have a high stake in maintaining the
epistemological legitimacy of disease entities. As long as disease is
something that takes possession of people, something they "catch" or
"get," the victims of these natural processes can be exempted from
responsibility for their condition. They can be pitied rather than
blamed for sloppy, vile, or incompetent performance in suffering their
subjective reality; they can be turned into manageable and profitable
assets if they humbly accept their disease as the expression of "how
things are"; and they can be discharged from any political
responsibility for having collaborated in increasing the sickening
stress of high-intensity industry. An advanced industrial society is
sick-making because it disables people from coping with their
environment and, when they break down, substitutes a "clinical," or
therapeutic, prosthesis for the broken relationships. People would
rebel against such an environment if medicine did not explain their
biological disorientation as a defect in their health, rather than as a
defect in the way of life which is imposed on them or which they impose
on themselves.33 The assurance of personal political innocence that a
diagnosis offers the patient serves as a hygienic mask that justifies
further subjection to production and consumption.
The medical diagnosis of substantive disease entities that supposedly
take shape in the individual's body is a surreptitious and amoral way
of blaming the victim. The physician, himself a member of the
dominating class, judges that the individual does not fit into an
environment that has been engineered and is administered by other
professionals, instead of accusing his colleagues of creating
environments into which the human organism cannot fit. Substantive
disease can thus be interpreted as the materialization of a politically
convenient myth, which takes on substance within the individual's body
when this body is in rebellion against the demands that industrial
society makes upon it.
In every society the
classification of disease—the nosology—mirrors social organization. The
sickness that society produces is baptized by the doctor with names
that bureaucrats cherish. "Learning disability," "hyperkinesis," or
"minimal brain dysfunction" explains to parents why their children do
not learn, serving as an alibi for school's intolerance or
incompetence; high blood pressure serves as an alibi for mounting
stress, degenerative disease for degenerating social organization. The
more convincing the diagnosis, the more valuable the therapy appears to
be, the easier it is to convince people that they need both, and the
less likely they are to rebel against industrial growth. Unionized
workers demand the most costly therapy possible, if for no other reason
than for the perverse pleasure of getting back some of the money they
have put into taxes and insurance, and deluding themselves that this
will create more equality.
Before sickness came to
be perceived primarily as an organic or behavioral abnormality, he who
got sick could still find in the eyes of the doctor a reflection of his
own anguish and some recognition of the uniqueness of his suffering.
Now, what he meets is the gaze of a biological accountant engaged in
input/output calculations. His sickness is taken from him and turned
into the raw material for an institutional enterprise. His condition is
interpreted according to a set of abstract rules in a language he
cannot understand. He is taught about alien entities that the doctor
combats, but only just as much as the doctor considers necessary to
gain the patient's cooperation. Language is taken over by the doctors:
the sick person is deprived of meaningful words for his anguish, which
is thus further increased by linguistic mystification.34
Before scientific slang had come to dominate language about the body,
the repertory of ordinary speech in this field was exceptionally
rich.35 Peasant language preserved much of this treasure into our
century.36 Proverbs and sayings kept instructions readily available.37
The way complaints to the doctor were formulated by Babylonians and
Greeks has been compared with the expressions used by German
blue-collar workers. As in antiquity the patient stutters, flounders,
and speaks about what "grips him" or what he "has caught." But while
the industrial worker refers to his ache as a drab "it" that hurts, his
predecessors had many colorful and expressive names for the demons38
that bit or stung them. Finally, increasing dependence of socially
acceptable speech on the special language of an elite profession makes
disease into an instrument of class domination. The university-trained
and the bureaucrat thus become their doctor's colleague in the
treatment he dispenses, while the worker is put in his place as a
subject who does not speak the language of his master.39
As soon as medical effectiveness is assessed in ordinary language, it
immediately appears that most effective diagnosis and treatment do not
go beyond the understanding that any layman can develop. In fact, the
overwhelming majority of diagnostic and therapeutic interventions that
demonstrably do more good than harm have two characteristics: the
material resources for them are extremely cheap, and they can be
packaged and designed for self-use or application by family members.
For example, the price of what is significantly health-furthering in
Canadian medicine is so low that these same resources could be made
available to the entire population of India for the amount of money now
squandered there on modern medicine. The skills needed for the
application of the most generally used diagnostic and therapeutic aids
are so elementary that the careful following of instructions by people
who are personally concerned would probably guarantee more effective
and responsible use than medical practice ever could. Most of what
remains could probably be handled better by "barefoot" nonprofessional
amateurs with deep personal commitment than by professional physicians,
psychiatrists, dentists, midwives, physiotherapists, or oculists.
When the evidence about the simplicity of effective modern medicine is
discussed, medicalized people usually object by saying that sick people
are anxious and emotionally incompetent for rational self-medication,
and that even doctors call in a colleague to treat their own sick
child; and furthermore, that malevolent amateurs could quickly organize
into monopoly custodians of scarce and precious medical knowledge.
These objections are all valid if raised within a society in which
consumer expectations shape attitudes to service, in which medical
resources are carefully packaged for hospital use, and in which the
mythology of medical efficiency prevails. They would hardly be valid in
a world that aimed at the effective pursuit of personal goals that an
austere use of technology had put within the range of almost everyone.
------------------------------
1 In this chapter I quote freely from documents gathered in Michel
Foucault, The Birth of the Clinic: An Archaeology of Medical
Perception, trans. A. M. Sheridan Smith (New York: Pantheon, 1973).
2 Walter Artelt, Einfühnmg in die Medizinhistorik: Ihr Wesen, ihre
Arbeitsweise and ihre Hilfsmittel (Stuttgart: Enke, 1949). An excellent
introduction to the methodology of medical history and its tools.
3 Heinrich Schipperges, "Die arabische Medizin als Praxis und als
Theorie," Sudkoffs Archiv 43 (1959): 317-28, provides a historiographic
perspective.
4 On the evolution of the hospital as
an architectonical element in urbanization, consult a dated monument:
Henry Burdett, Hospitals and Asylums of the World: Their Origin,
History, Construction, Administration . . . and Legislation, 4 vols.
(London: Churchill, 1893). Also Dieter Jetter, Geschichte des
Hospitals, vol. 1, Westdeutschland von den Anfängen bis 1850
(Wiesbaden: Steiner, 1966); several volumes planned.
5 Fernando da Silva Coreia, Origmes e formaqaõ das misericórdias
portuguesas (Lisbon: Torres, 1944). The first two hundred pages deal
with the hospital in antiquity and during the Middle Ages in the Orient
and in Europe. Jean Imbert, Histoire des hôpitaux français;
contribution à l'étude des rapports de I'église et de I'état dans le
domaine de l'assistance publique: les hôpitaux en droit canonique,
Collection L'Église et I'état au moyen âge, no. 8 (Paris: Vrin, 1947).
Well-documented guide to the sources of the medieval hospital and the
transition of public assistance from ecclesiastic to civilian control.
F. N. L. Poynter, ed., The Evolution of Hospitals in Britain (London:
Pitman, 1964); see the classified bibliography of British hospital
history, pp. 255-79. For the hospital in the New World consult Josefina
Muriel de la Torre, Hospitales de la Nueva España (vol. 1), Fundaciones
de las siglos XVII y XVIII (vol. 2), publications of the Institute de
Historia, Universidad Nacional, ser. 1, nos. 35, 62 (Mexico, 1956-60).
6 On the history of the hospital bed, consult F. Boinet, Le Lit
d'hõpital en France: Étude historique (Paris: Foulton, 1945); James N.
Blyth, Notes on Beds and Bedding: Historical and Annotated (London:
Simpkin Marstall, 1873). More general, but also more pleasant reading:
Laurence Wright, Warm and Snug: The History of the Bed (London:
Routledge, 1962). On good behavior when in bed, see work by Norbert
Elias cited in note 28, p. 166 below.
7 Marcel Fosseyeux, L'Hõtel Dieu aux XVIIe et XVIIIe siècles (Paris: Levrault, 1912).
8 For the origins and the evolution of the idea: David Rothman, The
Discovery of the Asylum (Boston: Little, Brown, 1971). Milton Kotler,
Neighborhood Government: The Local Foundations of Political Life
(Indianapolis: Bobbs-Merrill, 1969), makes a clear case for Boston. See
also Foucault, Birth of the Clinic.
9 It was
enjoined on Christian princes not to use life imprisonment as a
punishment because it was much too cruel. Prisons might be used to keep
criminals until their hearing, their execution, or their judicial
mutilation. Andreas Perneder, Van Straff und Pern alter undjeder
Malefitz handlungm ain kurtzer Bericht, ed. W. Hunger (Ingolstadt,
1544).
10 For documentation on the carefully
qualified and rich thought of Rousseau on medicine, see Gerhard Rudolf,
"Jean-Jacques Rousseau (1712-1778) und die Medizin," Sudhoffs Archiv 53
(1969): 30-67. Rousseau was probably misunderstood even more on
medicine than on education.
11 On the dream of
"wild" health consult Edward Dudley and Maximillian E. Novak, eds., The
Wild Man Within: An Image in Western Thought from the Renaissance to
Romanticism (Pittsburgh: Pittsburgh Univ. Press, 1972).
12 Jacques-René Tenon, Mémoires sur les hôpitaux (Paris, 1788), p. 451;
cited in Foucault, Birth of the Clinic, p. 17.
13
Brian Abel-Smith, The Hospitals, 1800-1948: A Study in Social
Administration in England and Wales (London: Heinemann, 1964).
Carefully documented on economic and professional changes. Leonard K.
Eaton, New England Hospitals, 1790-1833 (Ann Arbor: Univ. of Michigan
Press, 1957). See especially the bibliographical essay, pp. 239-46.
14 François Millepierres, La Vie quotidienne des médecins an temps de
Molière (Paris: Hachette, 1964). Popular but reliable; a composite
picture of the day-by-day life of the physician at the time of Moliere.
15 Jean-Pierre Peter, "Malades et maladies a la fin du XVIIIe siecle,"
in Jean-Paul Dessaive et al., Médecins, climat et épidémies à la fin du
XVIIIe siècle (Paris: Mouton, 1972), pp. 135-70: "During the French
Revolution the hospital, like the laboratory, both discovered around
1770, would play the midwife's role in the birth of these pre-existing
ideas."
16 Helmut Vogt, Das Bild des Krankm: Die
Darstellung äusserer Veränderungen durch innere Leiden and ihre
Heitmassnahmen van der Renaissance bis zu unserer Zeit (Munich:
Lehmann, 1960). More than 500 reproductions of artistic representations
of sick people since the Renaissance; allows a study of perception. For
a medical study of ergotism in the past based on its representation in
paintings, see Veil Harold Bauer, Das Antonius Feuer in Kunst und
Medizin (Heidelberg: Springer, 1973); bibliog., pp. 118-25; afterword
by Wolfgang Jacob, pp. 127-9. Painting and plastic arts provide an
invaluable complement to the history of patient-doctor relations: Eugen
Hollander, Die Medizin in der klassischen Malerei, 4th ed. (Stuttgart:
Enke, 1950). Eugen Holländer, Plastik und Medizin (Stuttgart: Enke,
1912).
17 W. Muri, "Der Massgedanke bei
griechischen Ärzten," Gymnasium 57 (1950): 183-201. H. Laue, Mass und
Mitte: Eine problemgeschichtliche Untersuchung zur fruehen griechischen
Philosophic und Ethik (Münster: Osnabrueck, 1960). Measure in antiquity
was related to virtue and proportion, not to operational verification.
On the prehistoric Indo-Germanic semantic field which includes both
measure and medicine see Emile, Benveniste, "Médecine et la notion de
mesure," in Le Vocabulaire des institutions indo-européennes, vol. 2,
Pouvoir, droit, religion, 1969, pp. 123-32. The English version is
Indo-European Language and Society (Miami: University of Miami Press,
1973).
18 For the history of measurements consult
two symposia: Harry Woolf, ed., Quantification: A History of the
Meaning of Measurement in the Natural and Social Sciences
(Indianapolis: Bobbs-Merrill, 1961), and Daniel Lerner, Quantity and
Quality: The Hoyden Colloquium on Scientific Method and Concept (New
York: Free Press, 1961). Particularly consult, in Woolf, the paper by
Richard Shryock, "The History of Quantification in Medical Science,"
pp. 85-107. For the application of measurement to nonmedical aspects of
man, see S. S. Stevens, "Measurement and Man," Science 127 (1958):
383-9, and S. S. Stevens, Handbook of Experimental Psychology (New
York: Wiley, 1951).
19 Richard H. Shryock and Otho
T. Beall, Cotton Mother: The First Significant Figure in American
Medicine (Baltimore: Johns Hopkins Univ. Press, 1954).
20 When disease became an entity that could be separated from man and
dealt with by the doctor, other aspects of man suddenly became
detachable, usable, salable. The sale of the shadow is a typically
19th-century literary motif (A. V. Chamisso, Peter Schlemihls
wtmdersame Geschichte, 1814). A demoniacal doctor can deprive man of
his mirror-image (E. T. A. Hoffman, "Die Geschichte vom verlorenen
Spiegelbild," in Die Abenteuer einer Sylvesnacht, 1815). In W. Hauff,
"Des steinerne Hertz," in Das Wirtshaus im Spessat (1828), the hero
exchanges his heart for one of stone to save himself from bankruptcy.
Within the next two generations, literary treatment was given to the
sale of appetite, name, youth, and memories.
21 For
this evolution in France, see Maurice Rochaix, Essai sur l'évolution
del questions hospitalières de la fin de I'Ancien Régime à nos jours
(Saintes: Federation hospitaliere de France, 1959), the only
well-documented history of public assistance to the sick in France. See
Jean Imbert, Les Hôpitaux en France, "Que sais-je?" (Paris: Presses
Universitaires de France, 1958), on the adaptation of the French
hospital to changing medical techniques during the 19th century. Of
course, consult also Foucault, Birth of the Clinic.
22 On the history of the concept of disease, see P. Diepgen, G. B.
Gruber, and H. Schadewaldt, "Der Krankheitsbegriff, seine Geschichte
und Problematik," in Prolegomena einer allgemeinen Pathologic (Berlin:
Springer, 1969), 1:1-50. Emanuel Berghoff, Entwicklungsgeschichte des
Krankheitsbegriffes: In seinen Haupzügen dargestellt, 2nd ed., Wiener
Beiträge zur Geschichte der Medizin, vol. 1 (Vienna: Maudrich, 1947).
Pedro Lain Entralgo, El médico y el enfermo (Madrid: Ediciones
Guadarrama, 1970).
23 Mirko D. Grmek, "La
Conception de la maladie et de la santé chez Claude Bernard," in
Alexandre Koyré, Mélanges Alexandre Koyré: L'Aventure de la science
(Paris: Hermann, 1964), 1:208-27.
24 Georges
Canguilhem, Le Normal et le pathologique (Paris: Presses
Universi-taires de France, 1972), is a thesis on the history of the
idea of normalcy in 19th-century pathology, finished in 1943 with a
postscript in 1966. On the history of "normality" in psychiatry see
Michel Foucault, Madness and Civilization: A History of Insanity in the
Age of Reason (New York: Pantheon, 1965).
25 For
the history of medical ideas during the 19th century, see Pedro Lain
Entralgo, La medicina hipocrática (Madrid: Revista de Occidente, 1970).
Werner Leibrand, Heilkunde: Eine Problemsgeschichte der Medizin
(Freiburg: Alber, 1953). Fritz Hartmann, Der ärztliche Auftrag: Die
Entwicklung der Idee des abendländischen Arzttums aus ihren
weltanschaulich-anthropologischen Voraussetzungen bis zum Beginn der
Neuzeit (Göttingen: Musterschmidt, 1956). M. Merleau-Ponty, "L'Oeil de
1'esprit," Les Temps Modemes, nos. 184-5 (1961), pp. 193 ff. M.
Merleau-Ponty, Phénoménologie de la perception (Paris: Gallimard,
1945). Werner Leibrand, Spekulative Medizin der Romantik (Hamburg:
Claassen, 1956). Hans Freyer, "Der Arzt und die Gesellschaft," in Der
Arzt und der Stoat (Leipzig: Thieme 1929). René Fiilop-Miller,
Kulturgeschichte der Heilkunde (Munich: Bruckmann, 1937). K. E. Hrag
Rothschuh, Was ist Krankheit? Erscheinung, Erklärung, Sinngebung, Wege
der Forschung, vol. 362 (Darmstadt: Wissenschaftliche Buchgesellschaft,
1976): 18 historically important critical contributions of the 19th and
20th centuries to the epistemology of sickness, among them C. W.
Hufeland, R. Virchow, R. Koch, and F. Alexander. Richard Toellner will
publish a parallel volume, Erfahrung und Denken in der Medizin.
26 On this development, especially as it centered around the influence
of Virchow, see Wolfgang Jacob, "Medizinische Anthropologie im 19. Jh.:
Mensch, Natur, Gesellschaft: Beitrag zu einer theoretischen
Pathologic," in Beiträge aus der allgemeinen Medizin, no. 20
(Stuttgart: Enke, 1967).
27Janine Ferry-Pierret and
Serge Karsenty, Pratiques médicales et système hospitaller (Paris:
CEREBE, 1974), an economic analysis of the rising marginal disutilities
to health care which have resulted from a take-over by the hospital in
medical care (the takeover was possible because of a hospital-centered
perception of disease). For a dozen sociological perspectives on the
contemporary hospital, consult Eliot Freidson, ed., The Hospital in
Modern Society (New York: Free Press, 1963). See also Johann J. Rhode,
Soziologie des Krankmhauses: Zur Einführung in die Soziologie der
Medizin . . . (Stuttgart: Enke, 1962), perhaps the most comprehensive
sociology of the hospital.
28 On the history of
body perception in European cultures, see Norbert Elias, Über den
Prozess der Zivilisation: Soziogenetische und psychogenetische
Untersuchungm, vol. 1, Wandlungen des Verhaltens in den Weltlickten des
Abendlandes; vol. 2, Wandlungen der Gesellschaft Entwurfzu einer Theme
der Zivilisation (Bern/Munich: Francke, 1969). (French translation,
Paris: Calmann-Levy, 1973).
29 An example: D. L.
Rosenhan, "On Being Sane in Insane Places," Science 179 (1973): 250-58.
"Once eight pseudopatients had gained admission to mental institutions
(by saying they heard voices), they found themselves indelibly labeled
with a diagnosis of schizophrenia—in spite of their subsequent normal
behavior. Ironically, it was only the other inmates who suspected that
the pseudopatients were normal. The hospital personnel were not able to
acknowledge normal behavior within the hospital milieu."
30 Thomas S. Szasz, The Myth of Mental Illness (New York: Harper &
Row, 1961). Thomas S. Szasz, Manufacture of Madness: A Comparative
Study of the Inquisition and the Mental Health Movement (New York:
Harper & Row, 1970). Ronald Leifer, In the Name of Mental Health:
Social Functions of Psychiatry (New York: Aronson, 1969). Erving
Goffman, Asylums: Essays on the Social Situation of Mental Patients and
Other Inmates (1961; paperback ed., New York: Doubleday, 1973). R. D.
Laing and A. Esterson, Sanity, Madness, and the Family (Baltimore:
Penguin, 1970).
31 Gregoria Hermann, La Santé
mentale en Chine, trans. A. Barbaste (Paris: Maspero, 1974). Original
title: La salud mental en China (Buenos Aires: Ed. Jorge Alvarez, 1970).
32 Peter Sedgwick, "Illness, Mental and Otherwise: All Illnesses
Express a Social Judgement," Hastings Center Studies 1, no. 3 (1973):
19-40, points out that events constitute sickness and disease only
after man labels them both as deviances and as conditions that are
under social control. He promises to raise the epistomological question
about sickness in general in a book soon to be published by Harper
& Row.
33 Albert Görres, "Sinn und Unsinn der
Krankheit: Hiob und Freud," in Albert Görres, ed., Der Kranke, Ärgemis
der Leistungsgesellschaft (Düsseldorf: Patmos, 1971), pp. 74-88.
34 B. L. Whorf, Language, Thought and Reality (New York: Wiley, 1956),
describes the language barrier that technical terminology creates
between the professional ingroup and the clients defined as the
outgroup. K. Engelhardt et al., Kranke im Krankenhaus (Stuttgart: Enke,
1973). While at the hospital, patients are intensively and
progressively mystified. At the time of dismissal less than one-third
have understood what disease they have been treated for, and less than
one-fourth, what therapy they have been subjected to. M. B. Korsch and
V. F. Negrete, "Doctor-Patient Communication," Scientific American 227
(August 1972): 66-9. In Los Angeles Childrens' Hospital, 20% of mothers
do not understand what ails their children, 50% do not grasp the
origins of their disease, and 42% do not follow the advice they
receive, frequently because they cannot grasp it. Raoul Carson, in Les
Vieilles Douleurs, rev. ed. (Paris: Julliard, 1960), confirms in a more
intuitive fashion that the same is true for his French patients.
35 For the language of disease in Mediterranean antiquity see Nadia van
Brock, Recherches sur le vocabulaire médical du Grec ancien: Soins et
guérison (Paris: Klincksieck, 1961). Hermann Grapow, Kranker,
Krankheiten und Arzk Vomgesunden und kranken Ägypter, van den
Krankheiten, vom Arzt and van der ärztlichen Tâtigkeit (Berlin:
Akademie-Verlag, 1956), 7:168. Georges Contenau, La Médicine en Assyrie
et en Babylonie (Paris: Librairie Maloine, 1938). For the language of
the Bible on disease, see references of note 44, p. 147 above.
36 Max Höfler, Deutsches Krankheitsnamen-Buch (Munich: Piloty &
Lohle, 1899). A monumental collection of German popular expressions
relating to organs, their functions, and disease in man and domestic
animals, as well as those which designate remedies, natural or magical;
922 packed pages.
37 Otto E. Moll,
Sprichwörter—Bibliographie (Frankfurt am Main: Klostermann, 1958),
lists 58 collections of proverbs in all languages dealing with "health,
sickness, medicine, hygiene, stupidity, and laziness" (pp. 534-7). In
contrast, for a history of medical language see Johannes Steudel, Die
Sprache des Arztes: Ethjmologie und Geschichte medizinischer Termini
(seen only in extracts).
38 Dietlinde Goltz, "Krankheit und Sprache," Sudhoffs Archie 53, no. 3 (1969): 225-69.
39 During the 19th century the new middle classes developed a sense of
guilt or shame about disease, while the upper bourgeoisie and nobility
turned their need for constant health care into an excuse for
fashionable "cures," particularly at spas. The "season" at the great
spas played a political function analogous to summit meetings today.
See Walter Ruegg, "Der Kranke in der Sicht der bürgerlichen
Gesellschaft an der Schwelle des 19. Jahrhunderts," and Johannes
Steudel, "Therapeutische und soziologische Funktion der Mineralbäder im
19. Jahrhundert," both in Walter Artelt and Walter Ruegg, eds., Der
Arzt und der Kranke in der Gesellschaft, des 19. Jahrhunderts: Vorträge
eines Symposions vom 1.-3. April, 1963 in Frankfurt a.M., Studien zur
Medizingeschichte des 19. Jahrhunderts, vol. 1 (Stuttgart: Enke, 1967).
R. H. Shryock, "Medicine and Society in the 19th Century," Cahiers
d'histoire mmdiale 5 (1959): 116-46. Luc Boltanski, "La Découverte de
la maladie: La Diffusion du savoir médical," mimeographed, Centre de
Sociologie Européenne (Paris, 1968). Based on much empirical data, this
paper gathers evidence for the class-specific diffusion of medical
civilization, and shows the economic origin of the poor man's
"hardiness" in the face of suffering and contrasts it with the
middle-class "struggle against pain."
One way to
explore reactions against the medicalization of disease perception is
to study the history of humor whose butt is the doctor. Materials on
caricatures can be found in U.S. National Library of Medicine,
Caricatures from the Art Collection, comp. Sheila Durling (Washington,
D.C., 1959); Helmut Vogt, Medizinische Karikaturen van 1800 bis zur
Cegenaiart (Munich: Lehmann, 1960); Curt Proskauer and Fritz Witt,
Pictorial History of Dentistry (Cologne: Dumont, 1970); A. Weber,
Tableau de la caricature médicale depuis les origines jusqu' à nos
jours (Paris: Éditions Hippocrate, 1936).