The Patient’s Story

As life must be possible before it can be pleasant, human health and its relation to survival and population growth are among the great themes of history. Why did early man, although apparently well-adapted to his environment, have high mortality rates and a short expectation of life? Why did the change from a nomadic to an agricultural existence ten thousand years ago lead to the predominance of infectious diseases as causes of sickness or death? What was the relation between population growth and agricultural and industrial developments? And where, among the nutritional, environmental, behavioural and medical advances of the past three centuries, are we to find the explanation for the decline of the infections and the modern transformation of health?

The variations in health and population size are interesting in their own right, but they are no less important in relation to their consequences. In Plagues and Peoples (1977) W.H. McNeill attributed the rise and fall of civilisations to the impact of infectious diseases, and writing of the growth of population in the Mediterranean in the 16th century, Braudel concluded: ‘This biological revolution was the major factor in all the other revolutions with which we are concerned, more important than the Turkish conquest, the discovery and colonisation of America or the imperial vocation of Spain. Had it not been for the increase in the number of men, would any of these glorious chapters ever have been written?... The increase lay behind all the triumphs and catastrophes of a century.’

Remarkably, medical historians have had little to say about the history of man’s health. The reason, I would suggest, is not that they were uninterested: it is that they believed the explanations for the changes were self-evident. Since the 17th century, medical thought has been dominated by the concept of the body as a machine whose protection from disease and its effects depends primarily on internal intervention. The modern improvement in health was assumed to be due to advances in medical knowledge applied through specific preventive and therapeutic measures, and the possibility that health was being transformed by changes in the conditions of life was not seriously considered. Hence histories of medicine, like histories of art, have two main themes, the great men and the great movements: Leonardo and the High Renaissance; Pasteur and the rise of bacteriology. Historians have written about the lives and works of Hippocrates, Galen, Paracelsus and Osler: but they have not inquired whether the great physicians were able to treat disease effectively. They have been concerned with the description of significant events in medical history, rather than with the central problems related to human health.

The deficiency in historical studies has begun to be recognised, and the Cambridge Monographs on the History of Medicine provide welcome evidence of the new approach. They are intended to cover ‘all aspects of health, disease, and medical treatment, being especially concerned with biological aspects of normal life, with patients, and with systems of health care’. The first volume, edited by Charles Webster, is of particular interest as an indication of the aims and methods of the series.

Health, Medicine and Mortality in the 16th Century is said (on the dust-cover) to be the first volume to deal with such a wide spectrum of issues related to health, disease and medicine for any period of English history, and the first to adopt throughout a quantitative basis for the problems under investigation. It is a comment on these claims rather than on the substance of the book to say that quantitative methods have been used in medical history for at least thirty years, and that six of the ten major essays are concerned with traditional themes and provide little scope for a numerical approach. They are none the worse for that. It is, however, to the other four essays that we must turn for an indication of the aims and methods of the new series.

What has been lacking in medical history is examination of past changes in health and of the part that medicine and other influences have played in relation to them. Even Sigerist, who was among the first to recognise the need for enlargement of historical interests, did not make a clear distinction between what doctors were doing and what they were achieving. ‘If you open a textbook, any textbook, of medical history and try to find what health conditions were in rural France in the 18th century, or what disease meant to a family of an artisan in the same period, you will as a rule not find any information. We know much about the great medical discoveries but very little on whether they were applied, or to whom they were applied.’ This extract from Sigerist’s essay on ‘The Social History of Medicine’ suggests that in spite of his broad concept of medical history, he did not recognise that the great discoveries of the past were not necessarily followed by any immediate benefits to the sick. It is important to know that three and a half centuries after the discovery of the circulation of the blood, the risk of a heart attack is probably greater (because of smoking) and the risk of death from an attack no less than it was in Harvey’s day.

The distinction between medical knowledge and effective treatment is clearly recognised by T.R. Forbes in his discussion of mortality and diseases leading to death in five London parishes from the 16th to the 19th century: ‘It is the story not of the doctor but of the patient, an account not of what contemporary medicine might do but of what it did – or more often did not do.’ Opinions will differ about the reliability of the parish records on which the examination is based, particularly in relation to causes of death as recorded intermittently by laymen, the searchers and the parish clerks. The conclusions about the level of mortality in Shakespeare’s day are, however, broadly consistent with later estimates: ‘For every 100 babies born in St Bardolph’s parish about 70 survived to their first birthday, 48 to their fifth, and 27-30 to their 15th.’ This suggests that for every one of the Elizabethans who left his mark on history, another two, perhaps equally gifted, had died before maturity. The loss was much greater than that which resulted from the First World War.

In his essay on ‘Mortality Crises and Epidemic Disease in England 1485-1610’, Paul Slack attempts to assess the frequency and causes of years of high mortality. His data are from parish registers, which recorded baptisms, marriages and burials, and from wills, which give some indication of deaths in the years before 1538 when the registers were first ordered. Slack is well aware of the deficiencies of these sources but nevertheless believes that certain deductions can be drawn from them. Perhaps his most important conclusion is that in spite of a high correlation between mortality and food prices in some localities, ‘mortality crises in Tudor England were not the direct result of food shortage or deteriorating standards of living.’ He attributes the crises largely to epidemic diseases such as plague and influenza which, he suggests, have no direct connection with malnutrition.

There is a detailed examination of diet in 16th-century England in an essay by A.B. Appleby. His findings throw some doubt on Chamfort’s aphorism: ‘There are two large sections to society: those with more dinners than appetite, those with more appetite than dinners.’ In Tudor England, dinners and appetite appear to have been positively correlated: the rich consumed large quantities of food and the poor and very poor were at times in or near starvation, which leads to anorexia. There was, however, a large ‘middling’ group who raised most of their own food and may have been spared from the ill-effects of excess and deficiency. The diets of the rich and the poor, already far apart, diverged still further during the 16th century, and in 1597, the year Henry IV was written, thousands died of starvation or of diseases brought on by malnutrition. Appleby concludes that the important question of the relation between malnutrition and infectious disease is still open.

The fourth paper indicative of the new approach to medical history is an investigation of ‘Infant and Child Mortality in England in the late Tudor and Early Stuart Period’, by Roger Schofield and E.A. Wrigley. This work is also based on parish registers, which begin before 1600 for about four thousand out of the total of 10,000 ancient parishes of England. After exclusion of many which, for one reason or another, were unsuitable, several hundred registers were considered adequate. The findings are drawn from family reconstitution studies for eight parishes.

The question which arises from this essay, and indeed from the others I have referred to, is whether the evidence from parish registers, wills, food prices and bills of mortality is enough to support the conclusions that have been drawn from it. Schofield and Wrigley feel able to accept their estimates of infant mortality and even to attach significance to minor changes (for example, from 134 to 142 deaths per 1,000 between 1550-99 and 1600-49). There are, however, several reasons for doubting the reliability of the figures. 1. The infant mortality rates are very low, much lower than those given by Forbes for the same period. 2. It is hard to believe that there was such wide variation in parish rates (from 90 to 222 deaths per 1,000 liveborn children). 3. It is even more difficult to accept that, at a time when infant mortality was high, variation was greater for deaths in the first month of life (for which the unfortunate term ‘endogenous’ is used) than for deaths in the later months.

If one accepts that past changes in health and population size are important subjects for investigation, it is essential to decide the means by which they can be tackled. For Scandinavia, birth and death rates are available from the mid-18th century, and in England and Wales cause of death was registered in 1838. Before those times the relevant data are in parish registers, wills, bills of mortality and the like. The deficiencies of these sources are well recognised. Nevertheless, following French practice, demographers and economic historians are devoting a great deal of effort to family reconstitution studies, in the hope that they will provide a reliable picture of national fertility and mortality trends, and even of the common diseases and the influences which produced them.

Yet the most significant conclusions based on this approach are plainly wrong. It has led to the idea that limitation of fertility was an important influence on health and population size; that it was so effective that the Malthusian adjustment of high mortality was unnecessary (because numbers and resources were in balance); and that it was the removal of restraints on fertility which initiated and largely accounts for the rise of population during the past three centuries. Yet numbers and resources were obviously not in balance in the early 18th century when the death rate was about thirty (per 1,000) and life expectation at birth was probably nearer 30 than 40 years. (The figures for countries such as Sweden today give us some idea of the level of mortality at which numbers and resources can be said to be in balance.) And it can readily be shown that an increase in fertility was not a significant influence on the growth of population, for if mortality had not fallen in the past three centuries, any increase in population size which resulted from a rising birth rate would have been offset by its later fall.

Medical historians also need to be acutely aware of the unreliability of observations on cause of death recorded, inconsistently, by laymen in earlier centuries. There were frequent errors in death certification by doctors after national registration in 1838, and even today, with all the advantages of laboratory, radiological and other procedures, a considerable proportion of the diagnoses made in hospital are not confirmed by post-mortem examinations. In the light of such findings, the ingenuity used in diagnosing disease in the 16th century on the basis of the seasonal distribution of mortality is clearly misplaced.

If evidence is needed that the cultivation of new territory in medical history should not lead to neglect of the more familiar ground, it is provided by the six excellent essays which form the bulk of Health, Medicine and Mortality in the 16th Century. Patricia Allderidge discusses the management of the Bedlam Hospital, one of the few to survive in the long period between the dissolution of the monasteries and the rebirth of hospitals under secular auspices in the 18th century. Margaret Pelling and Charles Webster examine the structure of medical practice. They show that the conventional idea that medical care was provided mainly by surgeons, apothecaries and university-trained physicians is quite inaccurate. There were many types of practitioners, male and female, trained and untrained, licensed and unlicensed, and the vast majority of the population of London received assistance from ‘the internal resources of the family, from neighbours, priests or finally from the local unlicensed male practitioners or wise women having no formal authorisation to practise medicine from either ecclesiastical or civil bodies’.

In view of the deficiency of trained and licensed practitioners, it is not surprising that there was a wide demand for medical knowledge among educated laymen, and Paul Slack has surveyed the vernacular medical literature of Tudor England. He concludes that although it was not a major factor in the provision of medical knowledge and treatment, it is of value to the historian as an indication of common assumptions and attitudes. In his introduction the editor suggests that ‘the main service of the medical writers was as compilers and translators, making available to the English public an amazingly wide spectrum of the most successful continental works.’ That some of the early writers had their wits about them is evident in this quotation from Phaer: ‘The best and most sure help in this case is not to meddle with any kind of medicines but to let nature work her operation.’

Most doctors and patients, however, were reluctant to let nature work her operation, and there was widespread interest in astrological and alchemical medicine – discussed in interesting papers by Alan Chapman and Charles Webster. Medical astrology was based on the supposed interaction between celestial influences and physiology, and its application usually combined astrological concepts with some form of physical medication such as blood-letting, purging or drugs. By the end of the 17th century, the idea of celestial influences had ceased to be a serious part of medicine, but a century earlier medical thought and practice had become deeply penetrated by alchemical and Paracelsian medicine: ‘The vigorous tradition of English alchemy promoted chemical therapy and created an intellectual atmosphere which was ideal for the incubation of Paracelsianism.’ Dr Webster outlines the background which led to this development and enabled it to provide a viable alternative to the entrenched system of the Galenic humanists.

The last of the major essays, by J.J. Bylebyl, discusses the School of Padua, to which many English students went because of its high reputation and because, although a Catholic university, it accepted Protestants. Among the important educational developments for which Padua was distinguished were the transformation of anatomical teaching, the institution of a botanic garden for medical purposes and the development of bedside teaching in the hospital. These changes were somehow accommodated within the conservative Galenic tradition.