RSS Feed for the unit The history of medicine: a Scottish perspective

Introduction

The Open University — Tue, 31 May 2011 15:18:19 GMT

This unit presents information about how Scottish healthcare institutions were influenced by the underlying social, economic, political and cultural contexts.

This unit is an adapted extract from the Open University course Medicine and society in Europe 1500-1930 (A218).

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Learning outcomes

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By the end of this unit you should be able to:

assess the specific problems concerning the health of a community;
describe how medical knowledge was a resource for, and was shaped by, broader cultural perceptions of the body.

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1.1 Introduction

The Open University — Tue, 31 May 2011 15:18:19 GMT

The ‘welfare state’ and its future are frequently a topic of passionate debate. Its philosophy, best embodied in the expression ‘from the cradle to the grave’, is based on the principle that one of the duties of the state is to care for the well-being of its citizens at each stage of their lives. Health is now recognised, at least in most European countries, as a universal right and many agree that its costs should be met by society as a whole and not just by those who are sick. Furthermore, one of the criteria by which we judge a society is its ability to maintain an environment that is clean and safe. All this, however, is very recent and is the fruit of struggles and controversies in the nineteenth and twentieth centuries. But what happened in earlier times? What did ‘disease’ and ‘health’ mean to communities regularly decimated by epidemics? What measures, if any, were taken? What happened to poor people, dependent on their ability to work, who could not afford the costs involved in falling ill? In this unit, I provide an example based at Edinburgh's Royal Infirmary to illustrate how changes in medical delivery affected the local population.

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1.2 The poor as patients

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Patients' accounts of hospital life in the early modern period are notoriously thin on the ground, so historians have turned to other sources. These include hospital registers, which became more detailed and accurate in the eighteenth century, and the notebooks of medical students, who were increasingly attracted to hospitals for on-the-job training. Both types of document have been extensively used to throw light on the daily routine of patients and the treatment they received. Here I draw extensively on the work of the historian Guenter Risse (1999) in relation to the Edinburgh Royal Infirmary.

The Royal Infirmary – a voluntary hospital – opened in Edinburgh in the 1740s. It was housed in an entirely new, four-storey building and replaced a much smaller hospital, which had been founded in 1729. The building comprised a central admissions room, several separate wards, lodging for the nurses, a kitchen and a pharmacy, as well as an amphitheatre, which was used for lectures, surgery and religious services. The city was prosperous and donations were generous: in addition to donations from a wide range of private benefactors, the hospital received money from the city guilds and the church (Figure 1). The hospital also had the full backing of the local college of physicians and of the university medical faculty. Edinburgh was fast becoming one of the most important and lively centres of medical education in the British Isles. The construction of this large hospital improved the teaching facilities and helped young physicians to expand their skills.

(Reproduced from Risse (1986), p. 83) ©

Reproduced from Risse (1986), p. 83.

Figure 1 When patients were discharged from voluntary hospitals, they often lacked the money to return to the place from which they had come, and consequently added to the number of beggars in the city. To reduce the burden on local workhouses, the governing body of the Edinburgh Royal Infirmary decided to ask sponsors also to pay for the cost of returning to their own homes the patients they had recommended for admission. Advertisement from the Edinburgh Evening Courant, 8 March 1775.

Long description

Exercise 1

Read ‘The medicalisation of the hospital in Enlightenment Edinburgh, 1750–1800: the case of Janet Williamson (1772)’, linked below, and then answer the following questions:

What took place during the admission process?
Why was Professor Cullen interested in Janet Williamson's case?
What treatment did Janet receive?

Click 'View document' below to open the reading.

View document

Discussion

Janet Williamson was a servant who had little or no family in Edinburgh. Feeling unwell, she applied to the infirmary for help. Admission was a two-stage process and took place in a purpose-built room. First, a patient had to prove that he or she was worthy of assistance. Janet presumably had a letter of recommendation which testified that she had a sponsor and therefore was deserving of admission; however, the name of her patron is not recorded. Risse suggests that her master may have contributed to the hospital's Servants' Fund. The second step was a medical check. The physician had to verify that she really was sick – faking an illness was a practice abhorred by the governors. The medical check also determined whether her symptoms matched the range of diseases that the hospital was prepared to treat. The hospital's policy was to avoid admitting patients who were suffering from incurable or contagious diseases. Two points worth noting are the entirely secular nature of the admission process and the complexity of the record keeping.
Professor William Cullen, who taught medicine at the university, was also in charge of the teaching ward at the infirmary. Janet was suffering from fever, and was admitted during a period in which Cullen was preparing a series of lectures on this disease. Cullen was keen to select interesting cases to present to his students, and so Janet was admitted to the teaching ward, where his lectures took place.
Janet was seen by Cullen, who took her pulse and prescribed bloodletting, emetics, enemas – still among the most popular medical procedures – and a special diet. A nurse looked after her, especially when she was delirious, and gave her regular fomentations of the legs and feet. Bloodletting was carried out by medical students. To treat Janet's cough, Cullen prescribed an expectorant, and he also ordered a blister to be raised on her back. Blistering was a time-honoured remedy to stimulate the body's reaction to a fever, but Cullen offered a new explanation for its efficacy. The treatment that Janet received seems to have been extremely thorough, and was probably no different from that which Cullen offered to his wealthy private clients.

So, the reason we know so much about Janet Williamson is because Cullen used the details of her case as teaching material, basing his lectures on the medical notes of patients in the ward register. However, this is probably the closest we can ever hope to get to the actual experience of patients in an eighteenth-century hospital. Even Risse, who investigated this subject in great depth, was forced to admit that many of his conclusions were the fruit of guesswork.

As the century drew to an end, and physicians gained the upper hand in hospitals, the use of patients as teaching material became normal practice, and the relationship between medicine and poverty took a new turn. Historians have argued that, in the nineteenth century, hospital patients – a group of people who usually had no family connections or means of support – became the object of growing medical experimentation. Fundamental changes in medical knowledge and practice took place in hospitals, including new ways of examining patients and regular post-mortem dissections, which in turn led to the establishment of a new discipline: pathological anatomy. These changes have been hailed as among the most important medical advances of their time, and it was the bodies of the hospitalised poor that made them possible (Risse, 1999, pp. 329–31).

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2.1 The sensible body

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For centuries, and well into the early modern period, sense experience, including seeing, hearing and touching, as well as bodily movement, had been explained according to the precepts of Galenic physiology – that is, as the result of the action of animal spirits flowing along the nerves between the brain and the periphery. Nerves were understood as hollow ducts that distributed animal spirits to sustain sensation and motion. In his groundbreaking model of the body as a machine, Descartes retained elements of this theory, though his emphasis on mechanical principles altered the Galenic understanding of nerves and muscles. His work also encouraged others to pursue further research into the notion of animal spirits and the anatomy of nerves, muscles and brain in order to account for movement and sensation.

In the second half of the seventeenth century, the structure of the nerves and the brain became the object of minute exploration. The Englishman Thomas Willis, for example, claimed that different parts of the brain performed different tasks and argued that the muscles contracted as the result of a chemical reaction occurring in the animal spirits. Gradually, the notion of animal spirits came to be replaced with that of a ‘nerve fluid’, which was consistent with the hydraulic model of the body prevailing at the time. The nerve fluid was conceived by some as the subtle and highly mobile secretion of the brain, which was widely thought to act like a gland. Sensation was due to the impact of external stimuli on the sentient extremities (skin, eyes, ears) and was transmitted by this fluid back to the brain.

The nature of this nervous fluid remained, however, a controversial topic in medical and scientific circles. Following Newton, many argued that the nerves were solid (not hollow), and that sensation and motion were the result of the vibrations (not the flow) of an ethereal medium – that is, an imperceptible, subtle and very elastic fluid, which was diffused throughout the universe, including animal and human bodies. Throughout the eighteenth century, physicians and philosophers argued over these different models, and sometimes combined them, for example by retaining the idea of the glandular function of the brain but conceiving of nervous transmission as a vibration rather than a flow (Jackson, 1970).

(Medizinhistorisches Institut, Bern) ©

Medizinhistorisches Institut, Bern

Figure 2 This is the engraved frontispiece of Haller's Mémoires sur la nature sensible et irritable des parties du corps animal [Treatises on the Sensitive and Irritable Nature of Parts of the Animal Body], 1756–60, in which he discussed the results of his investigations on the physiology of nerves and muscles. Vivisection on animals, as is shown taking place here, was a staple procedure of the research. Note also the collection of foetuses preserved in jars and the hanging skeleton. Often, the spaces used for natural investigations doubled their function as museums

Long description

A major change in making sense of how the nerves worked occurred when, after extensive physiological experiments, which involved cutting and stimulating the nerves of hundreds of animals, the Swiss anatomist Albrecht von Haller argued that the nerve fibres possessed an intrinsic and exclusive quality, which he called ‘sensibility’ (Figure 2). This quality, the capacity of the nerves to perceive outside stimuli, was located in their inner core. Tissues that possessed a rich network of nerves, such as the skin, also possessed sensibility to a high degree. Muscles too had a reactive property – they contracted in reaction to stimuli. Haller characterised this property as ‘irritability’. Published in 1752, Haller's findings were enormously influential and led to a major reorientation in medical theory. For example, they shaped the thinking of Scottish anatomists, such as Alexander Monro II (1733–1817) (Figure 3), and of the renowned professor of medicine at Edinburgh University, William Cullen.

(Wellcome Library, London) ©

Wellcome Library, London

Figure 3 Human nerves, from Monro's Observations on the Structure and Functions of the Nervous System, 1783

Long description

In the physiological model Cullen taught to his Edinburgh students, he described the body as a complex and highly integrated mechanism composed of solid organs, nervous system and fluids. While the proper functioning of each part was crucial to health, in Cullen's view it was in the nervous system that the ‘generative source of life lay’ (Stott, 1987, p. 133). He regarded sensibility and irritability as the most important qualities in an individual. For Cullen, sensibility was the capacity of nerves to receive sensation and transmit will: different people showed different degrees of sensibility. Irritability was a kind of nervous power possessed by the muscles and was quite distinct from their vigour. In fact, irritability and muscle strength were to be found in inverse relation to one another, so that a very strong person would also be prone to torpor, and a debilitated person would have a high degree of irritability. Health was now characterised by a balance between nerves' sensibility and muscles' irritability, while disease was the result of the deficiency or excess of these qualities. A certain degree of ‘excitement’ in the body was required for the nerves to transmit the impulses necessary to ensure bodily functions, but outside agents could either stimulate or depress this ‘excitement’. Remedies would either bring it back or reduce its excess. In locating the ultimate cause of disease in alterations of the nervous system, Cullen sneered at the importance traditionally attached to the fluids and their affections: ‘When I was first acquainted with Physic, I found Physicians reasoned very boldly, they spoke of thickening or thinning the blood with as much clearness as a Scotch maid would speak of making pottage thicker or thinner’ (quoted in Stott, 1987, p. 139). It was to the nervous system that physicians were now advised to direct their medical treatment.

Cullen's extensive correspondence with his wealthy patients provides numerous examples of the way in which he applied these new theories to his medical practice:

Your nervous system, originally weak, has received some shocks and your complaint is entirely from disordered nerves affecting both mind and body … You have got into a very relaxed state of nerves … I suspect your constitution originally has been strong but intemperance has been especially to blame and your first step is to avoid this for the future.
(quoted in Risse, 1993, p. 149)

If most patients continued to perceive diseases as the product of a blockage of the humours or extremes of heat or cold, some were gradually convinced that nerves were to blame: ‘Dr. Gem, Physician to ye Embassy, has exerted all his skills and knowledge … I have no Fever at present, I have head-Ache, and Indigestion, & I have lately been convinc'd that I have Nerves’ (quoted in Porter and Porter, 1988, p. 70). As a result of the shift from a hydraulic to a nervous model of the body, the notion of sensibility gained great popularity.

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2.2 The popularisation of ideas

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One of the media that helped to popularise the importance of nerves and the concept of sensibility was to be found outside medical encounters, in a new and extremely successful literary genre, the ‘novel of sentiment’. Writers such as Samuel Richardson, Laurence Sterne and Henry Mackenzie, who were familiar with the current medico-physiological debate, openly drew on these notions and made their characters' sensibility and response to external events the driving force of their writing (Barker-Benfield, 1992, pp. 15–36). By adopting the language of physiology as the tool with which to explore the emotional adventures of their heroes and, especially, their heroines, these writers contributed to circulating the idea that ‘delicacy of feeling’ and ‘a high sensibility’ should be regarded as the quintessential qualities of a human being (Figure 4). Not only were characters and plot now built around sentiments, but readers were also meant to respond with heightened ‘feeling’ to what they read. Never before had physiology so directly shaped literature, and never before had literature served medicine so well.

(Wellcome Library, London) ©

Wellcome Library, London

Figure 4 Richard Earlom, stipple engraving after George Romney, Sensibility, 1789. Unsurprisingly, the personification of sensibility in this picture is a young woman, whose bodily language expresses her heightened feelings, here anguish. Historians have argued that the emergence of sensibility brought about a certain feminisation of social customs

Long description

Exercise 2

Read ‘The popularisation of the new medical theories in the eighteenth century: the novels of Laurence Sterne’, linked below. Make a note of the various physiological concepts which, albeit expressed with much irony, pepper Sterne's writing.

Click 'View document' below to open the reading.

View document

Discussion

Extract (i) is a hymn to sensibility, which is praised for being not only the source of our feelings as individuals and a sort of divine presence in human beings, but also the basis for social bonding. It is because we feel that we are able to go beyond ourselves and act with compassion.

In extract (ii), the question of the origin of intelligence and the site and function of the soul in relation to the body is discussed with reference to the theories of famous philosophers such as Descartes and anatomists such as Bartholinus. In making fun of some of these theories – for example, by comparing the activity of the soul to that of a ‘tad-pole’ – Sterne assumes that his readers are at least conversant with discussions on the structure of the brain and the cerebellum, the intricacy of nerves and the location of the soul. Moreover, Tristram's father, a man deeply involved in these debates, who even proposes his own theory, was presumably a familiar character to contemporary readers. They would regard issues such as the source of intelligence, wit and memory as plausible topics of conversation between gentlemen with no specific scientific or medical expertise, though how it was conducted might stir a smile.

Through novels, a growing readership familiarised themselves with a whole set of expressions and concepts based on the ‘sensible’ body, which they might then apply to their own bodies, health and feelings. Despite Sterne's reference to the sensibility of the ‘roughest peasant’, sensibility was increasingly regarded as an attribute confined to those whose nervous apparatus was well developed. As opposed to coarseness, delicacy became a valued quality, which, though it might imply a tendency to develop nervous disorders, was generally perceived as socially positive.

To explain the success of this new model of the body, particularly in England and Scotland, Christopher Lawrence has looked at its broader social and political implications and argued that it served well a specific political and ideological project first proposed by eighteenth-century Scottish philosophers and politicians:

The nervous system gained importance in Scotland not only from the physiological side of the bridge but from the philosophical side also. In the second quarter of the century Scottish philosophy turned from reason to feeling, both as the basis of morals, and as the mainspring of action. On this foundation was developed a sophisticated theory of society and history, as well as a school of sentimental novel-writing … Scottish social thinkers discerned a relation between social life and the quality of sensibility. History was a process involving a gradual refinement of feeling.
(Lawrence, 1979, pp. 28–9)

The social implications of such thinking – found, for example, in the writings of such leading authors of the Scottish Enlightenment as David Hume (1711–76) and Adam Smith (1723–90) – were clear. Uncivilised populations and the labouring poor were regarded as devoid of sensibility, their skin, muscles and nerves being different from those of refined people. At the medical level, they were thus unlikely to develop nervous conditions. It is not surprising then that we find a clear distinction between the needs of different patients in Cullen's practice. Stomach problems, menstrual disorders, colic, hysteria and gout were the chronic ailments that characteristically afflicted his wealthy, private patients. In such cases, the best solution was to restore the balance of the nervous system through exercise, diet and the appropriate degree of stimulation. By contrast, poor, hard-working people could not afford to be as fussy about their health as the wealthy; nor could society in general, as Cullen explained:

Happily their manner of life and even their hardships are the best means of preserving their health. It is true that this is not universal and many men are doomed to employments more or less directly pernicious to health, but it is necessary for the good of the whole society, and the only compensation the society can make to them is the taking the greatest care of them, in disease and old age.
(quoted in Stott, 1987, p. 140)

Thus, political thought and medical theories successfully interacted in providing ‘rational’ justification for contemporary social hierarchy.

Finally, we might ask, what impact did the model of the sensible body have on therapy? Once again, the picture is a mixed one. As studies in electricity grew in the 1740s and 1750s, a link between nervous excitement and the regenerative and therapeutic value of electrical force was established. Machines generating shocks were devised and applied to cure a range of illnesses, including hysteria and paralysis. By acquiring one of these machines in 1750, the Edinburgh Infirmary made electric shock therapy available to the sick poor. As one physician observed, servants through ‘continual intercourse with people of decent manners’ acquired a ‘delicacy of body and sensibility of mind’ similar to that displayed by their employers (Risse, 1988, pp. 11, 15). However, following initial interest, learned physicians across Europe tended to become sceptical about the benefits of electrical therapy, which subsequently became the preserve of the numerous non-learned medical practitioners who thrived in the commercial economy of the late eighteenth century. Cullen did recommend electric shock treatment, but his favourite remedies to strengthen or relax the nerves were still diet, exercise, change of air and taking the waters. You may remember from the reading in Exercise 1 that to treat the servant Janet, Cullen prescribed the tried and tested procedures of applying fomentations, bloodletting and blistering. True, the rationale for these treatments had changed; by their use, Cullen was seeking to stimulate the nervous system, not purge the body. But for most of his patients, the notion of disease as the result of extreme hot or cold, humoral imbalance, impeded evacuations and blockage of the free flow of fluids still held true. Cullen's blisters and emetics were at one and the same time both innovative and traditional.

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3 Conclusion

The Open University — Tue, 31 May 2011 15:18:19 GMT

In the seventeenth and eighteenth centuries, a series of innovative models of the body was produced, from the mechanical to the mathematical to the sensible. As groundbreaking anatomical investigation and physiological experimentation were carried out, the map of the body changed, and different parts (vessels, glands, nerves) acquired visibility and became the focus of much research. New atlases and images of the body were produced to help students grasp the object of their study. We cannot dismiss the importance of these changes within medicine, nor their complex relationship with broader transformations in contemporary culture and society.

The construction of these diverse models of the body, however, represents only half of the story. When contrasted with the dramatic changes that occurred in nineteenth-century medicine – for example, the development of cell theory – the various models of the body I have discussed in this unit look very similar. This is apparent in the negligible change they brought to medical practice and the minimal impact they had on patients' expectations. As medical theories ebbed and flowed, the centuries-old holistic view of health and sickness survived almost intact in patients' narratives. For the vast majority, the body remained a system of closely interconnected parts, composed largely of vessels through which fluids moved and accumulated, causing imbalance and putrefaction. Disease, far from being located in one organ, was still thought to be the product of corrupt matter which travelled around the body and was able to affect any part of it. Such a holistic understanding was perfectly compatible with all the new medical theories, however different they were on the surface and in the eyes of their most partisan adherents. And it was this understanding, and the expectations it generated in the sick, which continued to set the agenda for most medical practitioners well beyond 1800.

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References

The Open University — Tue, 31 May 2011 15:18:19 GMT

Barker-Benfield, G.J. (1992) The Culture of Sensibility: Sex and Society in Eighteenth-Century Britain, Chicago and London, University of Chicago Press.

Jackson, S.W. (1970) ‘Force and kindred notions in eighteenth-century neurophysiology and medical psychology’, Bulletin of the History of Medicine, vol. 44, pp. 397–410, 539–54.

Lawrence, C. (1979) ‘The nervous system and society in the Scottish Enlightenment’ in B. Barnes and S. Shapin (eds) Natural Order: Historical Studies of Scientific Culture, Beverly Hills and London, Sage, pp. 19–40.

Porter, R. and Porter, D. (1988) In Sickness and in Health: The British Experience 1650–1850, London, Fourth Estate.

Risse, G.B. (1986) Hospital Life in Enlightenment Scotland, Cambridge, Cambridge University Press.

Risse, G. (1988) ‘Hysteria at the Edinburgh Infirmary: the construction and treatment of a disease, 1770–1800’, Medical History, vol. 32, pp. 1–22.

Risse, G. (1993) ‘Cullen as a clinician’ in Doig, A., Ferguson, J.P.S., Milne, L.A. and Passmore, R. (eds) William Cullen and the Eighteenth Century Medical World: A Bicentenary Exhibition and Symposium Arranged by the Royal College of Physicians in Edinburgh in 1990, Edinburgh, Edinburgh University Press, pp. 133–51.

Risse, G.B. (1999) Mending Bodies, Saving Souls: A History of Hospitals, Oxford, Oxford University Press.

Stott, R. (1987) ‘Health and virtue: or, how to keep out of harm's way: lectures on pathology and therapeutics by William Cullen c.1770’, Medical History, vol. 31, pp. 123–42.

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Acknowledgements

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Text

This unit was written by Dr Debbie Brunton

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 2.0 Licence

The material below is taken (and adapted for OpenLearn) from The Healing Arts Health, Disease and Society in Europe, 1500-1800 published by Manchester University Press in association with The Open University. http://www.manchesteruniversitypress.co.uk. Copyright in editorial selection The Open University. This publication forms part of the course A218 Medicine and society in Europe, 1500-1930.

Chapter 6 ‘Policies of Health: Diseases, poverty and hospitals’ and Chapter 7: ‘Old and New Models of the Body’ by Silvia De Renzi, Wellcome Lecturer in the Department of the History of Science, Technology and Medicine at The Open University.

Grateful acknowledgement is made to the following sources:

Figures

Figure 2 Medizinhistorisches Institut, Bern;

Figure 3 Wellcome Library, London;

Figure 4 Wellcome Library, London.

The material acknowledged below is contained in Health, disease and society in Europe 1500-1800 A source book (eds Peter Elmer and Ole Peter Grell) published by Manchester University in association with The Open University. Selection and editorial matter © The Open University 2004. This publication forms part of an Open University course: A218 Medicine and society in Europe, 1500–1930.

Grateful acknowledgement is made to the following sources for permission:

Guenter B Risse (1999) Mending Bodies, Saving Souls: A History of Hospitals published by Oxford University Press Inc. pages 231–51 © Guenter B Risse. http://www.gbrisse.com

Laurence Sterne (1983) The Life and Opinions of Tristram Shandy, Gentlemanm, ed. Ian Campbell Ross, pages 117–19, Oxford, Clarendon Press.

Laurence Sterne, A Sentimental Journey and Other Writings, ed. Tom Keymer, pages 95–9 (London, Everyman/J.M. Dent, 1994).

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