Health & Water in the Middle Ages

Health and Water in the Middle Ages: A Historiographical Survey

            As a requirement for life, water has enjoyed an interactive relationship with humanity through the ages, and this is no less true of the medieval era this survey will cover from about the ninth-century to the fifteenth AD. Because of its cleansing properties, symbolic associations, and the importance it is given in the Hippocratic and Galenic corpus, water has also often been associated with health — both as a healing agent itself and as a factor in the maintenance of the all-important equilibrium of the living body. It should come as a surprise, then, that the Anglophonic scholarship surrounding water and its role in medieval health can be best characterized as embryonic and fragmented, and certainly as lacking a developed methodological discourse or unity of approach.[1] Although calls have been made since the early twentieth-century for a more systematic analysis of medieval cleanliness, usage of and beliefs about water, and relationship with bathing and bathhouses, most scholars continue to focus on the early modern and modern periods.[2]

The piecemeal nature of extant work on the topic does, however, provide for an interesting and engaging range of research questions and approaches, in large part due to the myriad types of scholars that have an interest in water and health: these include geologists, archeologists, biologists, geographers, medical professionals (dermatologists, psychiatrists, and physicians), and historians from fields as varied as medical, architectural, cultural, and social history. One can only speculate as to what kind of product would result if these dynamic strands of intellectual work were united under the goal of a multi-disciplinary project on water and medieval health — which is exactly what this survey will attempt to do. By bringing together the many threads of English-speaking scholarship on the topic, I hope to outline the important strategies underlying each disciplinary approach and present a thematic and methodological synthesis — the groundwork, I hope, for further research in a relatively neglected but historically rich and informative area.

In the interest of covering one area in depth, I have neglected a few others. I did not include the scholarship on medieval Islamic beliefs about water’s role in health, nor have I covered its influence on Western beliefs and practice. A few of the sources I reference, however, do discuss this, particularly when they deal with Italian bathing practices, where proximity to Arabic civilizations facilitated especially vibrant intellectual and cultural exchange.[3] The time frame with which I have constrained my study leaves out many excellent studies on Roman, Greek, Germanic, Anglo-Saxon, and Renaissance bathing practices, some of which occasionally cover their influence on similar medieval traditions. I have additionally narrowed my focus to scholarship written in English. The historiography of bathing, spas, and the health regimen (particularly as pertains to water) is far more developed in the French and German tradition.

Water in Medieval Health

Medieval medical theory and practice in recent scholarship has begun to be understood as a system of knowledge and therapeutic methods that play off of and reinforce one another.[4] Indeed, within and without the professional, university-trained class of physicians, those involved in medicine generally adhered to the same basic concepts in their understandings of the body and its health or lack thereof.[5] Within this framework, water’s role in health becomes more intelligible. In the Greco-Roman-Islamic compendium, largely based off of writings passed down from the Hippocratic and Galenic corpus, then supplemented by Islamic commentators, the body is understood as a self-contained system of various elements. These humors — blood, yellow bile, black bile, and phlegm — need to be in the correct proportions to maintain a state of health for the overall organism. This theoretical framework underlay much of the preventative and restorative treatment recommendations of practitioners of the period.

A particularly relevant aspect of this set of beliefs, drawn primarily from Galen, is the group of factors affecting the equilibrium of the body known as the non-naturals. These “physiological, psychological, and environmental conditions,” including “air, exercise and rest, sleep and waking, food and drink, repletion and excretion, and… passions and emotions” were believed to play a vital role in manipulating the balance of the humors, and as such, an understanding of their effects often informed therapeutic practice.[6] This can be seen in the proliferation of regimen sanitatis, or health regimens, from the height of the School of Salerno onwards.[7] Practitioners and lay, literate men and women alike referenced these tracts both during times of health and illness for information on how their activities and lifestyle choices could be maintained or altered in the interest of their well-being.[8] Water appears quite often in this literature, a phenomenon that is reflected in the relative importance it takes on in therapeutic recommendations; baths of many different varieties and the drinking of water are both topics frequently discussed, and ideas about water’s role in human health also informed decisions about other sanitary practices, such as the regulation of communal water supply.[9]

Water: Narrative Absentee

Is water’s role in understandings and regulation of medieval health indeed a neglected area of scholarly endeavor, and to what extent has it been overlooked or underemphasized? To answer that, I consulted a few of what the Oxford Bibliography agrees are the most well received surveys of medieval medical theory and practice.[10]

Nancy G. Siraisi’s survey of medieval medicine, covering the middle of the twelfth to the fifteenth centuries, purports to encompass “western European literate and technical medicine and its practitioners.”[11] Chapter five, titled “Disease and Treatment,” presents an understanding of “the way medicine based on Greco-Islamic tradition worked in practice as a therapeutic system.”[12] To this end, Siraisi discusses the physician’s strategy of regulating the non-naturals through strict regimens designed to maintain a healthy bodily equilibrium, but she emphasizes the role of food and air in such tracts, neglecting the opportunity to discuss how water (applied topically via bathing or internalized via drinking) was also often a matter of import.[13] Hygienic practices are largely neglected. Her work presents the scarcest treatment of water and medicine of the works consulted, which is puzzling considering her focus on the way in which ancient medical theory — of which regulation of the non-naturals was an important aspect — was evident in the writing and practice of literate men of medicine.

A similar situation can be found in the medieval section of the collection of essays on medicine from the perspective of social history edited by Andrew Wear, Medicine and Society: Historical Essays. The compilation presents an attempt to integrate trends in social history into the field of medical history, pushing the discipline beyond great men and great inventions into looking at “how medicine has affected society and how society has shaped medicine.”[14] As bathing had its roots in social practice but was also associated with its effects on the body, historians concerned with society and medicine would do well to include at least a brief discussion of hydrotherapy in a survey. Katherine Park was chosen as the historian to cover the medieval period, and her treatment of water’s role in health is surface-level. She discusses hospitals’ preoccupation with hygiene, but she perpetuates the idea that medieval people had “low level[s] of collective hygiene” that “contributed to disease, particularly in the cities, where sewer systems were inadequate and water supplies often polluted by animal and human waste…”[15] This image of medieval filth and disregard for sanitary practice would likely be strongly contested by the historians of public health that will be discussed below.

Lastly, she argues that historians of health cannot possibly expect to paint a holistic picture of health in the middle ages “without considering the whole, including some kinds of health care — faith healing, for example, nursing, or midwifery — that no longer form part of our own more narrowly defined professional medicine.” To neglect these alternative forms of healing, she claims, “would yield a picture both incoherent and incomplete.”[16] Yet she does just that by failing to mention the important role of balneology and hydropathy — both of which would qualify as alternative medicine in the modern world — in preventative and combative therapy.

The last survey work consulted is an encyclopedia of medieval science, technology and medicine edited by Thomas Glick, Steven J. Livesey, and Faith Wallis. A brief historiographical summary of medieval medical scholarship can be found in the introduction; in it, the authors highlight a trend in the past two decades of the increased influence of social history, which has had the effect of directing interest to new areas of emphasis that include public health and the “medical marketplace” as opposed to the idea of a monolithic, university-trained monopoly on medical practice. Historians, they argue, have began to attempt an understanding of “medieval medical knowledge as a coherent system of ideas about the body, its disorders, and the potential for intervention…” and have looked at “how this knowledge did or did not affect actual practices… on the level of individual care and… social or political arrangements.”[17] Like Park and Wear, then, the editors of and contributors to the encyclopedia want to emphasize the many treatment options open to medieval people, and they also want to understand beliefs about health as a system in which various approaches to treatment fit.

Hydropathy and balneology embody the type of history many of these authors are attempting to write; it is a therapeutic practice outside the modern-day norm, practitioners recommending its use came from a variety of backgrounds, and its effectiveness was explained through the set of ideas about the body that make up humoral theory. Yet again, however, it is largely absent. The “Water Supplies and Sewerage” entry at least does medieval actors justice in portraying them as having the knowledge of and desire to regulate their water supplies and keep their cities relatively clean, but it does not delve deeper into how beliefs about the cleanliness of water and its effects on the body played into such decisions. The six non-naturals are mentioned on several occasions — in the “Meteorology” and “Regimen Sanitatis” entries — but the discussions under both are largely limited to the role of air and food in maintaining bodily equilibrium. To the book’s credit, it does emphasize the importance of the regimen sanitatis on “medieval practice and the lifestyles of millions of Europeans” due to its extension of “the physicians’ sphere of influence from the sick to the healthy,” an important distinction to be made about health and water in the Middle Ages.[18] Water was not only used in treating diagnosed illnesses, but was also a major player in preventing them.

Thus, it is clear that while many of the survey texts discussed above employ methodology that would seem to predicate the inclusion of medieval balneology and hydropathy, the practices and theories that underlay them remain largely absent from the ongoing narrative of health in the Middle Ages. In order to find scholarship that does discuss the role of water in healing, one must look beyond mainstream medieval medical history into the fringes of the discipline, and sometimes entirely outside of it into the realm of the sciences — a sure sign that a historical inquiry is in its infancy.[19]

Physicians and Scientists on Water and Health

            A physician by the name of Arnold C. Klebs, M.D., wrote one of the first historical accounts of bathing practices in the Middle Ages in his role as a member and contributor to the American Clinical and Climatological Association. The organization was founded in 1884 with the goal of improving medical education, research, and practice, and incorporating worldly, preventative, and environmental medical perspectives into scientific and medical literature.[20] With a view to that objective, Klebs aims to shed light on an era commonly assumed to be superstitious and relatively useless to medical men of the modern world; he hopes to understand medieval medicine within its own context, and with an awareness surprising for an early twentieth-century physician-turned-historian, discusses how the practice of balneology has been neglected due to the difficulty it presents those attempting to characterize medicine as an exact science. He advocates for an approach that considers actors outside what are typically thought of as men of early medical science, such as Antonius Musa, who made his mark in history as the founder of hydrotherapy when he cured Augustus with a cold bath.[21]

Klebs does not present an overarching argument other than his contention that medicine in the Middle Ages was not “dark” and uninformed, but was based upon knowledge about the body and how water affects it from a variety of authoritative sources. He traces the development of balneology from antiquity through the Middle Ages, using strategies borne out of etymology, archeology and architectural history, medieval history (with an emphasis on tracing the dates, authors, and influences on and of texts) and geography, and he employs sources as varied as letters, the songs of troubadours and minstrels, poetry, regimens, manuscripts, and governmental and monastic edicts in substantiating his claims regarding the nature of bathing and the factors that influenced its practice. Already, we can see that German scholarship in water and health is outpacing English interest in the same area; of the seven secondary sources Klebs cites, four are German, one is Italian, and two are English, and one of the English sources is a translation as opposed to critical work.

Thus, while Klebs’s work is largely descriptive, the methods he uses are very sophisticated (especially for someone not trained as a historian), and the general narrative he presents is roughly congruent with the current one — the rise of the bathhouse in the Middle Ages, influenced by Arabic, Germanic, and Greco-Roman practice, its development alongside that of university-stimulated medical theory, and its “degeneracy” in the later fifteenth century as the rise of Christianity and syphilis raised moral concerns. Where Klebs account excels in method, it lacks some measure of depth; beliefs are not explained in the context of medieval medical theory, which he seems to assume had very little to do with the actual practice of bathing. This could be attributable to the lack of scholarship on regimens and medical theory at the time of the piece’s composition.

Klebs’s thorough treatment, however, is the exception rather than the rule as far as scientists’ writing about medieval hydrotherapy is concerned. The next three sources will be dealt with in tandem, as their approach and relative emphasis on the Middle Ages render them comparable. They are all three from the mid-twentieth to the early twenty-first-century, at least a few full decades after Krebs’s contribution, and none of them cite Krebs’s work.

The first is probably the most respectable in that it does not get hung up on whether water actually works by modern standards as a therapeutic strategy. Written by four dermatologists and published in the scientific journal Clinics in Dermatology, the article attempts to outline the ways in which water — its prevalence in our daily lives rendered invisible by its integration into daily routine — has been understood in relation to health “throughout the centuries.”[22] The authors present a periodization, which includes the Greco-Roman world, the Dark Ages, the Medieval Period, the eighteenth and nineteenth centuries, and lastly, the twentieth. While giving due credit to Greco-Roman influences on medieval understandings of water and health, citing Hippocrates, Galen, and Asclepiades as developers of the theory and proliferators of the practice of bathing in and drinking water, they paint the Middle Ages as a period steeped in Christian influence and morally opposed to the evidently sexually-inundated practice of public bathing. They then skip directly to the sixteenth century with a brief mention of Arabic developments in the eleventh. Of the six columns of text, about half of a column concerns the medieval period, while the ancient, early modern, and modern periods receive at least a full column each. Klebs would have been horrified.

This relative neglect of the Middle Ages is also characteristic of the other two articles written by scientists.[23] Both cite as their goals the same as that of the dermatologists — to trace the historical use of water in therapy — although they add an important ulterior motive of discussing the efficacy of hydrotherapy in the context of modern medical science. It is in asking these types of questions that the authors’ lack of historical training and presentist tendencies become manifest. The narrative proposed in these pieces is almost identical to that of the one discussed above, but van Tubergen and van der Linden perpetuate the myth (to be discussed in further depth below) that the Middle Ages were a time of incredible filth. Due to the influx of Christianity and its institutional abhorrence for bathing, the authors claim, “People abstained from bathing, sometimes for years.”[24] All three pieces emphasize the pleasurable and recreational motivations for bathing, downplaying the role of medieval medical theory as an impetus for engaging in bath or spa therapeutics. It should be said in defense of these works, however, that they are at the very least asking questions and instigating investigations, rudimentary though they are, into the relationship between water and healing, and they include in their surveys the medieval period, which is oftentimes more than can be said for historians of medicine.

Physicians, psychiatrists, and dermatologists are not the only scientists to have contributed to the historiography of water and health in the medieval period. Geologists have also contributed to knowledge of the topic in the form of two articles within a collection of works titled A History of Geology and Medicine. The collaboration’s goal is to “explore the historical links between geology and medicine,” an endeavor, the editors claim, that is the first of its kind.[25] In addition to covering minerals, gems, fossils, and stones of all sorts, the work addresses groundwater as a geological phenomenon. One of the articles addresses British spa culture and is largely concerned with more recent history, but the contribution by Nick Robbins and Pauline Smedley, “Groundwater — Medicine by the Glassful?” takes up human interaction with water from natural springs as far back as the ninth-century BC. While, like the most other scientists, their primary questions are centered on whether or not groundwater was actually therapeutically effective, their explanations of how groundwater is stored, infused with minerals, and brought again to the surface are useful to any historian trying to understand some of the more geological aspects of water content and accessibility.

In addition to describing the processes that make groundwater available and imbue it with unique chemical properties, the article discusses the religious, mythical, and symbolic associations surrounding various historically famous springs and spas and correlate such beliefs with the actual properties of the water. The copper content at Llangamach Wells in central Wales, for example, was made famous and thought to be healthful due to its metallic taste — a characteristic, Robins and Smedly argue, that can be explained by the water’s high copper content.[26] They similarly point out that particular combinations of mineral content may have rendered some celebrated medicinal sources of water powerful diuretics and purgatives.[27] While the authors’ questions are problematic to the medical or medieval historian, geologists’ insight into the chemical composition of medieval water could prove helpful in understanding why certain sources acquired particular reputations, symbolic associations, and mythologies, and why medieval practitioners and patients may or may not have undergone different forms of hydrotherapy at various locations.

Since the historical scholarship on water’s place in medieval health is still very much in development, it is necessary to include work done by non-historians. Scientists and physicians have shown an interest in the subject matter, having seen in their experience working with hydrotherapeutic practice and water itself the important role today and in the past that water has taken on in narratives of health and disease. While their questions are not of the same nature as that of the historian, they have much to offer not only in bringing the subject to the attention of others but in developing strategies — some quite foreign to those trained in history — for understanding how water came to be associated with health and how such beliefs came to be reflected in medical maintenance, theory, and practice.

Archeology and Architectural History

            Archeologists and architectural historians have also had cause to discuss the role water has played in health in the Middle Ages. Jill Caskey’s case study of five bathhouse sites in Southern Italy is an excellent example. She approaches the topic from the perspective of an historian, hoping to integrate the recent interest of archeologists in excavating medieval bathing structures into her study of the architectural properties and attributes contained within them. She claims that, through a study of the physical structure of these bathhouses, the historian can hope to uncover not only trends in architecture that can shed light on the origins of medieval bathing practice, but in medieval bathing culture itself. She cites the tendency, exemplified by the articles surveyed in the previous section, to focus on Christianity’s ambivalent feelings toward bathing in the early Middle Ages and on the decline of the bath later on in the period and argues that a study of bathhouse structure can elucidate the far more complex way in which bathing was “deeply embedded in Campania’s architectural, social, economic, and scientific fabric.”[28]

She begins with a detailed description of the five medieval bathhouses from which she will base her conclusions, bringing to bear her knowledge about various architectural traditions on the structures to construct systems of possible influence; in the second half of the paper, she extends this to include cultural influences as well, weaving the two together to paint a picture of how Roman and Arabic building strategies and medicinal beliefs and practices made their mark on medieval Italian ones. Integrating the architectural and the cultural proves to be a very helpful explanatory strategy for understanding why and how medieval people chose to build and use bathhouses. She traces baths’ integration into the homes of wealthier Italians, monasteries, and even smaller rural homes — an excellent way to uncover the prevalence and importance of baths, for cultural or medicinal purposes. She comments as well on the technologies employed in these sophisticated structures. They often contained complex systems for acquiring, heating and cooling, steaming, and disposing of water, which speaks to medieval architectural ingenuity, Roman and Arabic influence, and the varied services the bathhouses were built to supply.

The structures provide other evidence of what their intended uses were. The sizes of bathing areas varied, some obviously designed for a single occupant. Shelving along the sides provided space for “a lamp and the accouterments of bathing — perfumes, oils, herbs, towels, and drinking vessels.”[29] The buildings contain rooms off of the side of those intended for bathing purposes for dressing and relaxing. Caskey does not limit her source base to the buildings themselves, but also includes the plans for their construction, artwork inside and outside of them, medical sources (like regimens and treatises), and even poems, deeds of sale, dowries, and wills that comment upon them in one way or another. She uses these documents to place the baths within their cultural and scientific context, and the result is a narrative that challenges notions of the Middle Ages as having been a time of filth and presents a multi-faceted hypothesis for why medieval bathers participated in the practice. Caskey relies heavily on archeological scholarship as well, citing items found at the sites she includes in her study as evidence of certain practices and understandings.

In Caskey’s methodological approach, architecture and culture exist in a reciprocal relationship — one that can be understood by historians and used to explain the important, varied, and ambivalent role bathing played in medieval beliefs about health and tradition. Including archeological and architectural sources provides a wealth of information very difficult to access from written sources about the origins of the practice, how it was conducted, and who participated, and supplemented by written sources, enable the historian to place this knowledge within a system of beliefs about health and the body. Indeed, including physical evidence adds considerably to the historical understanding of water’s role in health and is a strategy that should be employed more frequently in many areas of medieval medical history.

Hygiene and Cleanliness

            A growing number of medical historians have turned their attention to the study of cleanliness and dirt, a topic that invites many interesting questions about what historical actors have considered acceptably clean and why, and studies of this kind often naturally touch on the use of water for health purposes. Virginia Smith’s book Clean: A History of Personal Hygiene and Purity is part of this tradition, and hers is the first attempt at writing a history of cleanliness in over fifty years.[30] She views the study of hygienic practice as “a social and cultural history of preventative medicine,” as ideas about the maintenance of dirt are almost always intertwined with conceptions of “what we did… for ourselves in order to preserve our bodies.”[31] She thus gives primacy to medical concerns about cleanliness, a reflection of the relative importance such beliefs have played in decisions about hygienic practice. The book covers the beginning of humanity to the modern era, with two chapters that deal with the Middle Ages.

The first chapter concerns asceticism and presents an account that complicates the narrative of the religious aversion to bathing in the early medieval period. While early Christian concerns about nudity are not refuted, they are placed into context and shown to not always lead to an antagonism toward bathing. In fact, the early Christians’ belief in their duty to heal — coupled with medical understandings of health and cleanliness — often led them to construct bathing facilities in the hospitals and monasteries they built.[32] Smith additionally draws attention to the importance of water in religious cleansing rituals, most notably in baptism. This spiritual dimension no doubt played a major part in the health-giving attributes medieval people often ascribed to water, and its inclusion helps paint a fuller portrait of the more ethereal, less “scientific” reasons that individuals integrated water into their maintenance routines.

The second chapter tackles the myth of medieval filth head on, calling it an “exaggeration,” and a denigration of “the honor and dignity of [medieval housewives’] households.”[33] Smith uses a wide range of sources including manuscripts on household duties, accounts of the habits of men and women of note, clerics’ accounts and commentaries, songs, tapestries, and regimens in the vernacular (“the basis of public health education for the next eight centuries”). Particular attention is given to the regimens, which Smith claims were the avenue through which “the morning grooming session was institutionalized in medieval life” through the assertion that the cleansing recommendations they provided were backed by theoretical medicine.[34] She goes on to discuss the equally important role plague tracts played in establishing a normalized idea of medieval hygienic practice. Lastly, Smith touches on traditions that integrated bathing into their practice; springtime, for instance, was considered a prime season for bathing, as “it was also the Galenic time for bleeding and purging” — time for cleansing the body, inside and out.[35] Festivals were often organized with this in mind.

The strategies used in Clean are unique in their emphasis on the cultural and social aspects of bathing, and the way in which Smith contextualized such practices within a framework of medical theory provides a holistic account of why bathing would have appealed to a medieval audience. Her approach affirms the importance of cultural ideas in determining behavior, inviting the inclusion of sources sometimes neglected by historians of other fields like songs, vernacular texts, and descriptive accounts of court or monastic life. The mythologies and symbolic associations that surround water can be more clearly understood when their cultural backgrounds are supplied, and “cleanliness,” a cultural construct itself, is an effective framework for gaining access to this context.

Public Health Scholarship

            A subset of medical history, scholarship on public health has been scarce for the Middle Ages relative to other time periods, in large part due to the idea, discussed a few times already, that the period was mired in filth and had a general disregard for communal sanitation. This is rather astonishing considering that calls for a reevaluation of medieval cleanliness in general and of public health measures in particular has been trumpeted since at least 1928, the year Lynn Thorndike’s still oft-cited article on the topic was published in Speculum. In it, he identifies a three-headed Cerberus[36] of faulty beliefs about the Middle Ages: that the streets of medieval towns were disgusting; that bathing was rarely if ever practiced; and that organized public health measures were wholly absent. He asserts that such beliefs result from the tendency for people to assume a progressive historical narrative, and since “the survival of some such conditions [reaches] into rather recent modern times,” historians could only conclude that it must have been much worse hundreds of years ago.[37] To dispel the false assumptions he has identified, Thorndike cites historical evidence to the contrary in the form of government documents outlining sanitary practice and the appointment of town physicians, tracts describing medieval medical theory and its concern with filth, fleas and rats, and bathing as important for health, and the many architectural remnants of bathhouses and hospitals.

After such a sound refutation and a century’s worth of scholarship, it is surprising that public health historians of the twenty-first-century are still addressing and refuting the myth of a filthy Middle Ages in their work. Christopher Bonfield takes up the challenge in a 2009 article that argues not only that communal sanitary practice was prevalent, but that “medieval attempts to supply water often drew on medical, social, political, legal, and economic strategies.” He thus hones in on water sanitation in particular and attempts to explain why and through what logic the goals of such efforts were undertaken. Very prominent in his argument is the role of medical beliefs about water, which he asserts were the main impetus for public health legislation. Bonfield describes in detail the role of the non-naturals in Galenic literature, highlighting the importance of water, “which,” he claims, “was regarded as a real substance that could pass easily into the blood vessels and purify the human body.” Equally critical, and only understandable in the context of medieval humoral theory, was the “widespread awareness that, once contaminated water… entered the digestive tract, illness or even death might ensue.”[38]

In addition to explaining humoral theory, Bonfield tries to prove its pervasiveness by paying particular attention to its dissemination through vernacular texts like regimens and plague tracts; who was reading or being exposed to these texts, and how widespread were they? He cites statistical evidence that about 392,000 copies of vernacular texts containing medical advice were printed before 1500 and that literacy was more widespread than commonly believed.[39] The author also discusses how “spiritual investment” in clean water influenced medieval public health; he describes the way in which civic and church authorities funded sanitation enterprises in exchange for salvation. Again, religiosity is shown to be intimately linked to water and cleanliness. Like most other authors considered in this survey, Bonfield employs regimens and commentaries, but his focus on public health necessitates the inclusion of legislative and punitive sources. These provide evidence of the ubiquitous concern about the cleanliness of water, largely the result, Bonfield argues, of beliefs about water’s ability to effect health.

Coomans and G. Geltner take up a similar argument in their collaborative piece published in 2013. They extend their study into Dutch bathhouses as well, asserting that adherence to Galenic medical theory underlay both bathing practices and public health initiatives in the Middle Ages. The authors assess the role of Galen’s work in shaping popular understandings of the body, emphasizing his belief that preventative medicine should take precedence — which, they assert, helps explain why “water management was closely linked to the preservation of life’s basic necessities.”[40] This applied both to keeping communal streets and water sources clean and to maintaining the integrity of bathhouses, which, in accordance with the importance bathing was ascribed in medical texts, was paramount to preserving the overall health of a town. Coomans and Geltner utilize sources as diverse as legal statutes, officials’ charters, the records of city officials, and the customary treatises and regimens to substantiate their claims.

Thus, as the scholarship on public health initiatives in the Middle Ages has developed, the medieval understanding of water’s role in health has become a topic of increasing import. Why regulate the purity of something unless it is understood to be a useful endeavor for those exposed to it? When placed into the context of the Galenic understanding of health and the body, it becomes clear that clean water and reputable bathing establishments would have been desirable to people in the Middle Ages, just as public health legislation sheds light upon how deeply ingrained medieval medical theory was in popular understandings of the body, health, and water’s capacity to influence both.

Conclusion

Although mainstream medical historians have largely neglected water’s relationship to the theory and practice of medieval health, work in other areas has provided a foundation for a more thorough treatment of the subject. We can learn from extant work in social history how informative viewing medieval medical theory and practice as two complementary and reciprocally reinforcing parts of a larger system of knowledge can be. In the context of humoral medicine, water was seen as one of many factors (albeit an especially important one) that influenced the ever-changing body, and as such, its place in health becomes intelligible. The regimen sanitatis and plague tract are two source bases that have been widely used to place hydrotherapeutic practice within the wider framework of humoral medicine.

Cultural historical methods also prove useful; the mythologies and symbolic associations water has historically been ascribed can often be grounded in cultural, religious, or spiritual influences as well as theoretical ones, which helps to explain how such practices endured so long and maintained such ubiquity. To this end, historians have employed an incredibly wide variety of sources that include but are certainly not limited to commentaries and personal accounts, religious texts, poetry, and the songs of minstrels. Additionally, “hard” evidence like architecture, artifacts, and even the geological properties of water sources can be harnessed to provide ways to trace influence and to elucidate the practice and prevalence of hydrotherapy and balneology in the Middle Ages. Some of these strategies fall outside the traditional purview of the historian, but as proven in Jill Caskey’s, Nick Robin’s, and Pauline Smedly’s work, they can be incredibly revealing.

Historians of public health have insightful work to offer up as well. Their focus on medieval efforts to maintain public well-being have included the use of sources like legal and administrative statutes, official documents, and city records to prove that medieval people were very health-conscious and often based their health decisions within the context of a loosely unified medical theory. They saw the value of preventative medicine. Indeed, the study of water and health in the Middle Ages helps facilitate scholarly inquiry into preventative medicine, the relationship between medical theory and practice, therapeutic practices that are no longer considered “scientific,” and the cleanliness of the period, all aspects of the medieval era that are in need of further consideration. Work focused distinctly on the topic, as it stands only pursued by scientists and physicians, is long overdue. The foundations have already been laid and simply await an historian to build upon them.


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Smith, Virginia. Clean: a history of personal hygiene and purity. Oxford: Oxford University Press, 2007.

Thorndike, Lynn. “Sanitation, Baths, and Street-Cleaning in the Middle Ages and Renaissance.” Speculum 3, no. 2 (1928): 192-203.

van Tubergen, A. and S. van der Linden. “A brief history of spa therapy.” Ann Rheum Dis 61 (2002): 273-275.

Wear, Andrew ed. Medicine and Society: Historical Essays. Cambridge: Cambridge University Press, 1992.


Notes

[1] This assertion does not extend to work on the topic in the French and German tradition, where the scholarship is far more developed. Both sources listed on the Oxford Bibliography for Medieval Medicine under “Regimen and Bathing,” for example, are French.

[2] Take, for instance, Roy Porter’s 1990 Medical History supplement, The Medical History of Waters and Spas — the closest thing to a collaborative survey of medicine and water. Of the ten contributions, one deals with the classical world, one with the Renaissance, and the other studies address topics temporally located from the 17th to 20th centuries. The Middle Ages are thus entirely neglected.

 

[3] See Jill Caskey, “Steam and ‘Sanitas’ in the Domestic Realm: Baths and Bathing in Southern Italy in the Middle Ages,” Journal of the Society of Architectural Historians 58, no. 2 (1999): 170-195.

[4] See Nancy G.. Siraisi, Medieval and Early Renaissance Medicine (Chicago: University of Chicago Press) 1990, 78-79 and Thomas F. Glick, Steven Livesey, and Faith Wallis, “Introduction,” in Medieval Science, Technology, and Medicine: An Encyclopedia eds. Glick, Livesey, and Wallis (New York: Routledge, 2005).

[5] Nancy G.. Siraisi, Medieval and Early Renaissance Medicine (Chicago: University of Chicago Press, 1990), 78-79.

[6] Siraisi, Medieval and Early Renaissance Medicine, 101; Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: W. W. Norton & Company, 1997), 107.

[7] Porter, The Greatest Benefit to Mankind, 107.

[8] Porter, The Greatest Benefit to Mankind, 107-108; Christopher Bonfield, “Medical Advice and Public Health: Contextualizing the Supply and Regulation of Water in Late Medieval London and King’s Lynn,” Poetica 72 (2009), 6-7.

[9] Bonfield, “Medical Advice and Public Health”; J. Coomans and G. Geltner, “On the Street and in the Bathhouse: Medieval Galenism in Action?” Anuario de Estudios Medievales 43, no. 1 (2013): 53-82.

[10] Peter Murray Jones, “Medicine,” in Oxford Bibliographies in Medieval Studies. Accessed 25-Apr-2017.

[11] Siraisi, Medieval and Early Renaissance Medicine, 115.

[12] Ibid., 116.

[13] Siraisi, Medieval and Early Renaissance Medicine, 120-123.

[14] Andrew Wear, “Introduction,” in Medicine and Society: Historical Essays ed. Andrew Wear (Cambridge: Cambridge University Press, 1992), 1.

[15] Katherine Park, “Medicine and society in medieval Europe, 500-1500,” in Medicine and Society: Historical Essays, 62.

[16] Katherine Park, “Medicine and society in medieval Europe, 500-1500,” in Medicine and Society: Historical Essays, 60.

[17] Thomas F. Glick, Steven Livesey, and Faith Wallis, “Introduction,” in Medieval Science, Technology, and Medicine: An Encyclopedia eds. Glick, Livesey, and Wallis (New York: Routledge, 2005), viii.

[18] “Regimen Sanitatis,” in Medieval Science, Technology, and Medicine: An Encyclopedia eds. Glick, Livesey, and Wallis (New York: Routledge, 2005), 439.

[19] The first generations of medical historians were largely comprised of physicians, just as practicing scientists generated much early interest in the history of other sciences. Pierre Duhem provides a good example; he was a mathematician and physicist who became interested in European science in the Middle Ages, and he was one of the first to see the importance of medieval contributions to science.

[20] “American Clinical and Climatological Association,” The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions, accessed Apr. 20, 2017.

[21] Arnold C. Klebs, “Balneology in the Middle Ages,” Transactions of the American Clinical and Climatological Association 32 (1916), 17.

[22] Hirak Behari Routh, Kazal Rekha Bhowmik, Lawrence Charles Parish, and Joseph A. Witkowski, “Balneology, Mineral Water, and Spas in Historical Perspective,” Clinics in Dermatology 14 (1996), 551.

[23] A. van Tubergen, and S. van der Linden, “A brief history of spa therapy,” Ann Rheum Dis 61 (2002): 273-275; William A. Frosch, “’Taking the Waters’ — springs, wells, and spas,” The Journal of the Federation of American Societies for Experimental Biolgoy 21 (2007): 1948-1950.

[24] van Tubergen and van der Linden, “A brief history of spa therapy,” 273.

[25] Christopher J. Duffin, “Geology as medicine and medics as geologists,” in A History of Geology and Medicine eds. C. J. Duffin, R. T. J. Moody, and C. Gardner-Thorpe (London: The Geological Society, 2013), 3.

[26] N. S. Robins and P. L. Smedley, “Groundwater — Medicine by the Glassful?” in A History of Geology and Medicine (London: The Geological Society, 2013), 264.

[27] Ibid., 265.

[28] Jill Caskey, “Steam and ‘Sanitas’ in the Domestic Realm: Baths and Bathing in Southern Italy in the Middle Ages,” Journal of the Society of Architectural Historians 58, no. 2 (1999), 172.

[29] Ibid., 173.

[30] Virginia Smith, Clean: a history of personal hygiene and purity (Oxford: Oxford University Press, 2007); Douglas Biow, review of Clean: a history of personal hygiene and purity, by Virginia Smith, Bulletin of the History of Medicine 82, no. 3 (2008): 709-710.

[31] Virginia Smith, Clean: a history of personal hygiene and purity (Oxford: Oxford University Press, 2007), 3.

[32] Ibid.,141-142.

[33] Ibid., 145.

[34] Virginia Smith, Clean: a history of personal hygiene and purity (Oxford: Oxford University Press, 2007), 154.

[35] Ibid., 176.

[36] His brilliant wording, not mine.

[37] Thorndike, Lynn. “Sanitation, Baths, and Street-Cleaning in the Middle Ages and Renaissance,” Speculum 3, no. 2 (1928), 192.

[38] Christopher Bonfield, “Medical Advice and Public Health: Contextualizing the Supply and Regulation of Water in Late Medieval London and King’s Lynn,” Poetica 72 (2009), 4-6.

[39] Ibid., 7

[40] J. Coomans and G. Geltner, “On the Street and in the Bathhouse: Medieval Galenism in Action?” Anuario de Estudios Medievales 43, no. 1 (2013), 59.

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Disease as Framework

Medical historians, medical anthropologists, and other scholars concerned with a plethora of topics have written works centered around specific diseases; what comprises their arguments, evidence, and conclusions, however, varies greatly and begs the question, what exactly is the history of a disease, and how have scholars employed disease as a schema through which they analyze other topics? This essay will attempt to provide specific examples of historians (and anthropologists and literary scholars) using illness as a framework, and it will elucidate the benefits, drawbacks, and consequences of such work.

Few medical historians would argue with the statement that a disease is a constructed entity. The biology of an illness constitutes only a part of its meaning to the society from which it emerged. Oftentimes, there are non-biological factors — “beliefs, economic relationships, societal institutions,”[1] to name a few — that also make up the concept that is a particular disease. Syphilis is a good case in point. The biology of the disease is fairly standard; it is a bacterial infection that, if left untreated, can become quite serious. Because of the way that it is transmitted, however, syphilis has garnered a scandalous reputation and has been associated with sin since its appearance in Europe in the late 1400s. The way the disease was handled institutionally (syphilitics were often banned from hospitals or placed in homes amongst one another) and the way that sufferers experienced it (often shunned from society, and when treated at all, given needlessly harsh “remedies”), shows that it was, at least in the eyes of the religious societies it ravaged, much more than what its biological attributes would suggest.[2]

If, then, diseases carry in their conceptions more than their biologies, studying the way that people, institutions, practitioners, and societies in general interact with illness can tell us a lot about that society, and by centering their work around certain diseases, historians can look at the specific aspects of society those diseases’ definitions are ingrained within. A study of syphilis, for example, would prove insightful to a historian looking at religion, morality, and sexuality, as these abstract principles were entwined within contemporary understandings of the disease. Anyone commenting on syphilis in the fifteenth and sixteenth centuries was likely to have something to say about the immorality and sexuality of the sufferers, as juxtaposed with the more religious individuals who kept the scourge at bay with their superior righteousness and adherence to stricter moral codes. Disease can help a historian tease out the more intricate, sometimes contradictory beliefs societies and individuals have held, and as a universal if not experience, at least anxiety, disease is something that everyone — rich or poor, young or old, educated or illiterate — would have run into and held assumptions about.

The universality of disease does not imply that the experience of disease has been homogenous. As some of the works included in this essay will attest, disease has played into already extant lines of difference between segments of a population. It can isolate and stimulate discourse on these populations at the fringes of society; German measles did so for women and for the disabled, as Sickle Cell Anemia did (and continues to do) for African Americans.[3] It can bring visibility to groups of people, prompting humanitarian action, as cholera did for some of the poorest individuals in nineteenth century New York.[4] It can also serve to condemn, as many believed AIDS did when it struck down a disproportionate number of homosexual males during its rampage in the 1980s.[5] Whatever the case may be, it is clear that diseases can tell many stories, and as such provide an excellent avenue through which historians can understand the social, economic, political, and medical dynamics of a group of people.

The stories a disease tells are greatly influenced by which division of an affected population the writer chooses to vivify and how those individuals interacted with the illness (or the ill) themselves. A primarily institutional perspective, such as the one adopted by Charles Rosenberg in The Cholera Years, will provide insight into major ideological trends; state and national responses to the cholera epidemic in the mid-1800s included prayer and fasting, while just a few decades later, methods from the public health sector (quarantine and cleaning cities) dominated the institutional response. This outlook can highlight major changes in theoretical and practical understanding and in who holds institutional power (in this case, the medical experts or theologians). While this method offers much by way of the ideological leanings of the academically and socially significant members of the populace, it also leaves many actors out of the narrative. The experiences of the practitioner and the invalid factor very little into these stories, to the detriment of their plenitude.

In contrast, an author may choose the opposite route and focus instead on the experience of the afflicted, as S. Lochlann Jain does in Malignant. This method offers in-depth analyses of the experience of the disease itself — it answers questions about what was and was not available to sufferers, and how they were treated by their friends, families, doctors, and governments. Jain exposes corporate fundraisers for cancer research as short sighted and opportunistic, just as she points out inconsistencies and holes in the healthcare system for young adults (the seemingly healthiest segment of the population). Her unique perspective comes from someone having dealt with the disease firsthand, and the insights she offers as a result circle primarily around that perspective. It is quite powerful, but like all viewpoints, it is not universal, and it fails to elucidate the institutional standpoint; the doctors who treat cancer day after day, for instance, do not have a voice in Jain’s work. It is extremely difficult to trace larger trends in theoretical, scientific, or practical understandings held by the scientific community, the government, or various medical associations from the sole perspective of those they attempt to care for.

The final potential perspective of disease lies with those who probably spend the most time surrounded by it — the practitioner. In some ways, the perspective of the doctor encompasses both the institutional narrative and the personal one. The practitioner can serve as a go-between, as a representative of larger medical and governmental bodies who brings institutional wisdom to the commoner. By the same token, doctors can provide those suffering with a voice in an institution; in many nineteenth century epidemics, for instance, it was the doctors of a town, not the government, who provided the impetus for a public health board and suggested quarantine or cleaning measures. It would seem that this perspective would be ideal, but doctors often have outside motivations such as professional advancement (or establishment in the case of pre-twentieth century practitioners), political agendas, and personal belief systems that influence their treatment of certain patients (many doctors during the AIDS epidemic, for instance, felt they had little responsibility to treat a disease caused by sinful homosexuality).[6] Their perspective must be subject to the same sort of scrutiny one would employ when analyzing any story told from a single viewpoint and is best supplemented with others.

Most of the works in the following analysis employ multiple perspectives in telling their histories of disease, but each work tells a story that might have been told many different ways from different perspectives. What the author chooses to include — whose story of illness they decide to impart — depends upon what other entity, idea, or phenomenon they are attempting to understand. By using disease as a framework, the following authors are playing on the intersections between the wider, socially constructed definition of a disease and the society and time that experienced it. Through the excited, fearful window disease offers into the past, the following books, by utilizing the various perspectives offered, paint pictures that, while certainly include the diseases themselves, also give form to other processes, phenomena, and belief systems that constitute the societies whose reactions form the bases of the studies.

The Cholera Years

The first work to be dealt with here is Charles Rosenberg’s dissertation-turned-book The Cholera Years: The United States in 1832, 1849, and 1866. It is first not only because it is a stellar example of disease as framework; it was also trailblazing, as evidenced by the fact that many of the other pieces dealt with cite it when describing their methodologies. As one of the first works to use heightened disease anxiety (most often in the form of an epidemic), Rosenberg’s work presents an excellent starting point. The book is predictably divided into three sections, one devoted to each outbreak, and focuses on the different governmental and sometimes institutional reactions to each subsequent epidemic.

The post-colon portion of the book’s title betrays the focus, on the United States in three snapshots in the nineteenth century, instead of on cholera itself. The outbreaks, Rosenberg states in the introduction, “represented a constant and randomly occurring stimulus against which the varying reactions of Americans could be judged.”[7] In other words, each time cholera threatened the nation, Rosenberg could trace the reactions of its citizens and compare them with those before and those after. By using cholera as a framework of analysis, he could reach an understanding of societal changes, and, he asserts, the processes that brought them about in mid-nineteenth century America.

Rosenberg focuses on a few particular changes he sees through the reaction to cholera. First and foremost, the religious dimensions of the response, he claims, see marked change from 1832 to 1866. The piety so characteristic of Jacksonian America had faded to the background by 1866, replaced by a rise in materialism. This he traces through responses to cholera epidemics, in which he finds the clergy having decreased authority, and an increased tendency to fault uncleanliness as opposed to alcoholism and other, unrelated vices as cause of cholera emerges in newspapers and commentaries by medical and governmental authorities. Another line of theoretical change Rosenberg defines in his study is that of disease causation. In 1832, cholera was seen as a miasmatic entity that, in combination with uncleanliness and immorality, brought down primarily the poor and filthy. By the 1866 epidemic, however, most physicians believed that cholera was indeed a specific disease, caused by the ingestion of “some quantity of a specific poison,”[8] although the exact nature of its constitution would have to wait until 1883 when Robert Koch isolated the true culprit, Vibrio cholerae.

Dangerous Pregnancies

            Leslie J. Reagan’s Dangerous Pregnancies: Mothers, Disabilities, and Abortion in Modern America is a book about the German measles epidemic of the 1960s in America, although the disease around which the book is centered does not even make the title. This is because, as Reagan reveals in her introduction, the book uses German measles as a framework of analysis:

“This history investigates these cultural products and effects and uses the disease to identify the approaches of American parents to pregnancy and family, the role of ordinary Americans and patients in the creation of law and political movements, the state’s relationship to the responsibilities of its citizens, and the development of citizen rights and expectations.”[9]

Her work, while made possible by an epidemic, does not find its center around the disease that ravaged the American family in the mid-twentieth century. Instead, her book aims to understand the many effects this event had on those it touched (directly or remotely); because it affected childbearing women, an integral part of the population, it had direct ramifications for the political and social atmosphere of 1960s America.

Dangerous Pregnancies, with a source base that includes newspaper articles, court cases, images, educational pamphlets, and magazines, encompasses many angles of experience. Mothers of disabled children find a voice in magazine articles, just as scientists and medical professionals are represented by specialized medical literature and government documents. Images feature prominently in the text, because, as Reagan asserts, they “produced a dominant cultural climate that gave shape to people’s understanding of German measles, its consequences, and the possibilities for social change.”[10] The author is attempting to paint a portrait of 1960s America — one that could only be possible in such vivid detail through the window provided by the German measles epidemic.

Through this window, Reagan is able to discuss the unique climate that German measles helped provide for the burgeoning reproductive rights movement. She artfully discusses how the biology of the disease — a biology that allowed it to cross the placental barrier and mark fetal development — produced unprecedented anxiety about fertility and the future, particularly potent in a post World War II America that was already rife with concerns about its ability to maintain power internationally. What made German measles especially unique, Reagan argues, was that it became associated with the white, middle class, a trustworthy group that garnered much attention and sympathy from laypeople and professionals alike. When white, heteronormative, wealthy women had need of abortions, a social movement to provide them legally resulted. This is starkly juxtaposed with the difficulties African American women often found when attempting to undergo the same procedure. In this case, a disease-based framework helps us to understand the ability of a respected, trusted group to enact social change under the ominous threat of debilitating illness, while at the same time pointing to the flagrant undercurrent of racism that continued to marginalize and deny equitable medical care to certain segments of the population. The contrast is stunning.

Dangerous Pregnancies is probably the most inclusive book surveyed here as far as breadth and integration of multiple perspectives go. Unlike some of the other works discussed in this piece, Reagan’s does not neglect the scientific side of the story. She includes in her narrative the development of a vaccine for German measles, and doctors’ and government officials’ thoughts and statements feature prominently. Reagan addresses race, class, and gender issues; she even throws in a few anecdotes that bring in the male experience of the disease, although her primary focus is on women’s encounters. The inclusion of legal proceedings, a rather atypical source base, gives a voice to customarily hidden actors like Sandra Gleitman and Barbara Stewart, two relatively normal American mothers who were told by their doctors that their contraction of German measles early on in their pregnancies would have no effect on their children (which was well known to be medically untrue). By incorporating the patient, the doctor, and the institutional perspective, Reagan offers a wholesome and well-researched portrait of a society, its culture, and the development of its laws, all through the use of a period of heightened anxiety made possible by a disease and its contemporary cultural understanding.

The Collectors of Lost Souls

With Warwick Anderson’s book The Collectors of Lost Souls, we transition into a different research tradition, but one that also utilizes disease as an explanatory tool. Anderson was trained as an anthropologist, and his work could be considered history of science, history of medicine, and/or medical anthropology. The conglomerate approach seems appropriate, however, as the story Anderson tells is itself interdisciplinary. His study traces the American and Australian discovery and subsequent research of a disease and a people living in the eastern highlands of New Guinea, placing emphasis on the interactions between the two groups, the commodification of Fore body parts (brains in particular), and the development of scientific and institutional understandings of kuru, the disease that came to be identified with the islanders. Anthropologists, virologists, and myriad other specialists were involved in the gathering of samples for study and transporting them to laboratories capable of the research, the physical experiments and trials run in order to understand the cause of the disease (for which there is no known cure), and the public health efforts aimed at stymying the epidemic by informing the Fore of its cause — their practice of cannibalizing their dead.

Anderson’s approach mirrors the others in strategy. In his introduction, he identifies kuru as a “social sampling device,” and “[a] potent stimulus to scientific activity” capable of “capturing the culture of biomedical investigation in the second half of the twentieth century.”[11] Scientists keen on making their reputations flocked to research opportunities like kuru presented, and for good reason; Stan Prusiner, the man who isolated the pathogenic protein fragments that caused kuru, won a Nobel Prize for his work on the disease in 1997.[12] Anthropologists jumped at the opportunity to conquer a new research frontier. The disease provided the impetus for the intense anthropological and medical investigation that ensued, furnishing a reason for the Fore and the scientists that descended upon them to interact, exchange goods, and form relationships.

Anderson uses the environmental set-up kuru created to comment on the dynamics of specimen isolation, creation, and distribution that was characteristic of the scientific investigation of kuru and of biomedical investigation in general in the late twentieth century. Field scientists operated as nodes in a network of exchange that included the kuru and remote laboratories and that was populated by specimens taken from kuru bodies. D. Carleton Gajdusek, a field anthropologist that features prominently in Collectors of Lost Souls, traded goods from the first world with the kuru in exchange for their deceased’s body parts, which he then traded within institutionalized scientific networks for professional prestige. Through an intense analysis of this dynamic, Anderson is able to pull apart and understand the intricate social implications inherent in both channels of exchange, and by juxtaposing them, provides deep insight into the complex colonial relationships developed in a twentieth century research hotspot.

Like all the works in this survey, Anderson’s use of disease as a framework makes visible a dynamic cast of characters; his scope of analysis includes the field anthropologists and scientists who interacted with the kuru, the scientists analyzing diseased samples in laboratories around the world, and occasionally the institutions sponsoring the research. The kurus’ voices are less animated than some of the others in his narrative, and although this seems to be a problem with available source material rather than one of methodological deficiency, their relative silence is problematic. How can we truly understand the dynamics of exchange between a native population and medical colonizers without the voice of the former? While it has its problems, Warwick Anderson’s use of kuru as a device to capture twentieth century science’s imperialistic nature and its toleration of commodification of the colonized was overall successful. It was in the unique medico-scientific environment provided by kuru that medical imperialism could flourish and first world scientists could be confronted and changed by their interactions with a culture and its socially constructed diseases.

Malignant

Also coming from an anthropology background, the next work’s author, S. Lochlann Jain offers a firsthand account of her experience with cancer. Filled with snarky social commentary, Malignant is another example of a book that uses a disease’s many tendrils into the social and cultural landscape to analyze chosen aspects of society. While less of a historical work than the others featured here, Malignant provides an opportunity to understand how a more personal account — written not with patients’ perspectives in mind, but by an actual patient — can be useful. Jain’s insight into the medical establishment and the cultural and social experience of someone with cancer is something that the institutional and professional perspectives could never shed light upon. Through Malignant and Jain’s sharp, penetrating work, we can understand what a patient’s perspective has to offer, and, equally important, what it does not.

In her introduction, Jain works very hard to emphasize the cultural understanding of cancer; its biology is mentioned only in reference to how it gives the disease meaning in the context of society. Cancer, she argues, is difficult to define because it encompasses so much more than its biology. “[A] devious knave,” “cancer” is composed of the treatments (and their effects and stereotypes), an entire research industry (that chooses what to research and has a plethora of motivations that do not always include a cure), political groups lobbying for or against carcinogen regulation, and the politicians that choose what approach the government should take on the devastating scourge, just to name a few entities, technologies, and people involved. And yet, Jain points out, we do not have a cure, “…despite some of the shiniest, priciest, most marble-staircased hospitals in the country.” Cancer becomes a noun seemingly too simplistic to envelop the myriad meanings it evokes.[13] It is, in Jain’s words, “not… a disease waiting a cure, but… a constitutive aspect of American social life, economics, and science…a process and… a social field.”[14]

Cancer as a complex medico-cultural entity, far removed from its, in retrospect, rather simplistic biology is the framework Jain then uses to analyze her (and by extension, every patient’s) experience with the disease. Because her definition is so expansive, she has the opportunity to extend her analysis far beyond sufferers, doctors, and medical and governmental institutions, and she does so with headstrong ferocity. Her thesis — that cancer has become an integral part of American life culturally and economically — requires such breadth of inquiry. She touches on topics as diverse as pharmaceutical companies being deincentivised to develop and distribute specific (and therefore more effective) cancer drugs, the psychological effects of the reductionist, numerical approach to treatment, and the knowledge and experience gap between doctor and patient. Her source base is broad, consisting of scientific articles, popular news sources, advertisements, statistics, court documents, and more, all supplemented by personal anecdotes and experiences. This would imply integrating multiple perspectives, but none are fleshed out. Although she references many perspectives for her arguments’ sake, one is clearly dominant in her work.

At the risk of sounding reductionist, cancer is a disease; while it has many cultural manifestations and effects that make it unique and important, it is a large claim indeed to assert that cancer is as central to American culture, politics, and economics as Jain does. This is one of the weaknesses of the patients’ perspective; when threatened with a life-altering (and sometimes ending) illness, an individual would see it everywhere. Like Jain herself argues, it is difficult when diagnosed with cancer to remain an individual — sufferers lose their individuality to the disease, and it is difficult to gain it back. They either die or become a “cancer survivor,” and everything, including their perceptions and reasoning, can easily become influenced by their frightening and tragic experiences.

Malignant fails to provide practitioner and institutional perspectives, and as a result, its content is skewed by the vision of a single angle, albeit a powerful one. Jain fails to present why the statistical approach is used, and she leaves out the many success stories the current system has accomplished. While her work is very important — it highlights issues inherent in the way cancer is conceptualized and handled that could garner support for meaningful changes, and it offers a valuable look at the cancer experience from an articulate, thoughtful actor within — it fails to capture broader scientific and theoretical understandings of the disease. Without such an understanding, it is very difficult to explain the current system in a fair light, and paired with Jain’s irreverent commentary, a biased interpretation is the result.

The Wages of Sin

The last book to be included in this survey was authored not by an anthropologist or a historian, but a literary scholar. Peter Lewis Allen wrote The Wages of Sin: Sex and Disease, Past and Present about many diseases; greatly affected by the AIDS epidemic of the 1980s, Allen approached his work differently than most others. His experience with institutional responses to AIDS, and their subsequent effect upon a vulnerable and suffering population, sent him looking for the roots of such phenomena. What he came up with was a consortium of illnesses that had historically been associated with sin, sexual deviance (as was the case with AIDS) being a major component of most eras’ beliefs on immorality. He thus isolated an aspect of society to look at — conceptions of sin — and found examples of diseases with cultural definitions that included a dimension of immorality.

In an attempt to establish a timeline from the Middle Ages — “the cradle of the modern world” — to the AIDS epidemic, Allen chose illnesses that he perceived as exemplary of his theoretical hypothesis from 1000AD to the modern era.[15] A disease would emerge and become associated with vice, and subsequently, those afflicted with it would be treated poorly by medical institutions and practitioners alike. His case studies include lovesickness and leprosy in the Middle Ages, syphilis and the Bubonic Plague in the early modern period, masturbation (or “onanism”) in the nineteenth century, and, of course, AIDS in the twentieth century. By looking at the way that institutions and practitioners characterized the disease and those that carried it, Allen tries to show institutional discrimination based on sexuality, morality, religiosity, and lifestyle. His source base includes medical tracts, theological treatises and sermons, and, especially in the chapters on more recent diseases, personal accounts and government-sponsored pamphlets.

The biggest issue with Allen’s work lies in his approach. Though he is open about his bias, like S. Lochlann Jain, his experiences with socially stigmatized disease colored his interpretive approach to his research. Instead of taking the diseases as the complex and multi-faceted entities they are, Allen focused on a single aspect of their definition — their cause — and even within that narrow framework considered only perceived causes that supported his argument.

Even while writing within a context of patient injustice, Allen’s source base is primarily composed of institutional and practitioners’ perspectives. This is perhaps due to a lack of sources for patients’ experiences, but it presents a methodological issue; how can we understand the hardships that theoretical links between disease causation and morality impart upon the ill when their experiences are not vivified? True, the practices outlined by doctors for the treatment of syphilis sound heinous — mercury, one of the most popular anecdotes for the disease, caused “excessive salivation, loosening of teeth, pain and numbness in the extremities, uremia, renal damage… vomiting, dizziness, convulsions, tremors, liver damage, anorexia, severe diarrhea, and mental deterioration”[16] — but as mentioned in the introduction, if this information comes from doctors, their motivation and biases may have influenced their writings. Without the voices of the oppressed, Allen’s argument is difficult to bring to satisfying fruition.

In a way, the book Allen was trying to write is nearly an impossible endeavor. Diseases cannot be reduced to a single dimension of their complex and intricate social understanding; when a writer does so, he or she is oversimplifying the issue to the point of historical inaccuracy. Yes, sufferers of AIDS certainly experienced very real discrimination as a result of their affliction being associated with sexual deviance, but some doctors and politicians did not share this view. As the case of Ryan White, a child diagnosed with AIDS whose school community attempted to keep him from attending for fear of infection, shows, anxiety about HIV was multifaceted and concerned with more than just homophobia. Although is work is useful in that it highlights major ideological trends in disease conception and association with morality, its value as an example of employing disease as a framework of analysis is notably lackluster.

Conclusion

Diseases are complex entities that require in-depth and multi-faceted approaches to properly understand, but through their complexity, they have amazing capabilities as frameworks of analysis. Because their definitions are so expansive, and because they touch so many aspects of social and cultural experience, they can provide an excellent inroad into issues that might at first seem unrelated. Leslie Reagan demonstrated how they can uncover race and gender issues inherent in medical care and political activism, and Peter Lewis Allen exhibited how they can be used to understand morality and blame. Equally important is the way diseases can provide environments of heightened anxiety that present a society’s prejudices, fears, and motivations in microcosm, ripe for analysis. Warwick Anderson made use of the atmosphere kuru created in order to understand networks of scientific and anthropological exchange, just as Charles Rosenberg utilized epidemics of cholera, and the abundant commentary they bred, to trace changing ideas about disease causation and religiosity. The power of disease for any historian is hard to contest.

In order for a framework of illness to avoid biases, however, it is important for researchers to be inclusive. Acknowledging the complexity of socially constructed definitions of diseases is paramount, and to do so, an author must incorporate more than just a single perspective. Illness is experienced by different players in the game that constitutes dealings with disease in different ways, and a methodology that only employs a single angle, or even does not employ all of them — the patient, the practitioner, and the medical institution with which both are associated — will produce only a piece of a complex and difficult puzzle. Many of the works surveyed here fell into this trap, to the detriment of the integrity of their work. They may have maintained useful arguments and made points worth pursuing, but their narratives were nonetheless incomplete if they did not incorporate the many experiences that make up disease.

 

 

[1] Robert A. Aronowitz, “Lyme Disease: the Social Construction of a New Disease and Its Social Consequences,” The Milbank Quarterly 69, no. 1 (1991): 79.

[2] Peter Lewis Allen, “Syphilis in Early Modern Europe,” in The Wages of Sin: Sex and Disease, Past and Present (Chicago: University of Chicago Press, 2000).

[3] See Leslie J. Reagan, Dangerous Pregnancies: Mothers, Disabilities, and Abortion in Modern America (Berkeley: University of California Press, 2012) and Keith Wailoo, Dying in the City of Blues: Sickle Cell Anemia and the Politics of Race and Health (Chapel Hill: University of North Carolina Press, 2001). Although not included in this survey, Wailoo’s work also utilizes disease (in this case, sickle cell anemia) as a framework of analysis.

[4] Charles Rosenberg, “Poverty and the Prevention of Disease” in The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962).

[5] Peter Lewis Allen, The Wages of Sin: Sex and Disease, Past and Present (Chicago: University of Chicago Press, 2000), xvii.

[6] Peter Lewis Allen, The Wages of Sin, xviii.

[7] Charles Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866, 4.

[8] Ibid., 219.

[9] Emphasis added. Leslie J. Reagan, Dangerous Pregnancies (Berkeley: University of California Press, 2012), 2.

[10] Leslie J. Reagan, Dangerous Pregnancies, 3.

[11] Warwick Anderson, The Collectors of Lost Souls: Turning Kuru Scientists into Whitemen (Baltimore: Johns Hopkins University Press, 2008), 5.

[12] Ibid., 202.

[13] S. Lochlann Jain, Malignant: How Cancer Becomes Us (Berkeley: University of California Press, 2013), 2.

[14] Ibid., 4.

[15] Peter Lewis Allen, The Wages of Sin, xix.

[16] Peter Lewis Allen, The Wages of Sin, 55.