Doctoring the past

Is there such a thing as the history of the body, and, if so, how might we study it? The idea of the body as a constant, a given, whose components and attributes must always be there to be known or discovered, seems self-evident to the medical patient, the medical practitioner, the micro-biologist of the present day. Much writing in medical history takes it for granted that our current approaches to knowing and describing the body correspond exactly to an objective reality which has been unchanging over time, and that matching the medical treatises and descriptions of past eras against this reality is an unproblematic exercise.

Barbara Duden argues strongly that this is a simplistic view which, at the very least, makes it impossible for us to understand either the medical practice of the past or the changing ways in which the body has been experienced; it also blinds us to the fact that even modern, ‘scientific’ medical terminology reifies as objective physical states and processes what are more properly seen as subjective intellectual constructs. And she wishes us to go further still and to ‘start from the assumption that the imagination and perceptions of a given period have the power to generate reality.’

The title of her book in the original German edition is Geschichte unter der haut, which Harvard University Press has translated as The Woman beneath the Skin. The implication that where history is, woman is not, and where woman is, history is not, is in this case quite peculiarly inappropriate. Duden’s minute study of the case histories collected by the Eisenach physician Johann Storch in his eight volumes on the diseases of women published between 1747 and 1752 is not only a major essay in the historiography of the 18th century, but one which demonstrates the relative insignificance of gender as a defining category in this period.

Storch was born in 1681 in a village of six hundred inhabitants where both his father and grandfather had practised as tailors, local healers and dealers in herbs and medicines. Unlike them, he studied medicine at the University of Jena, where he undertook the dissection of cadavers, and was exposed to the ‘progressive’ theories of Georg Ernst Stahl, Wolfgang Wedel and Friedrich Hoffmann, all of whom were concerned to question traditional doctrines of the humours. The University licensed him as a practitioner, and he settled in Eisenach to build up a professional career.

What his case histories demonstrate is how little impact Storch’s anatomical training had on his subsequent perceptions of physiological processes. As Duden puts it, ‘the dead body did not yet cast its shadow on the living body.’ What lay beneath the skin ‘could be grasped only as the place of an experienced but invisible flowing’. This benign flow found outlets not only in conventional orifices, but in wounds, lumps and pores. Substances like breast milk were credited with the capacity to move about the body and to undergo constant metamorphoses – into faeces, a rash, an inflammation. These were all forms of ‘humoral matter’; and they manifested the healing power of nature, and its invisible intentionality.

For Storch, the body was the site of infinite possibilities, from which he did not attempt to derive a norm. This had important implications for his conceptualisation, or rather non-conceptualisation of gender. Distinctions between male and female were hedged about with qualifications and exceptions; the possibility of male lactation was not ruled out, and male piles could be considered as a condition equivalent to the menses. Even pregnancy was an ambiguous state, which did not privilege the category of gender: the womb was likened to other organs such as the lungs and stomach; and since the failure of menstrual blood to flow brought a woman close to the perilous state of ‘stagnation’, the physician could legitimately and routinely prescribe ‘cleansing’ agents which might well be abortifacients.

Given the absence of conceptual and diagnostic norms, the physician’s perceptions were much closer to the patients’ view of themselves than can possibly be the case today. Storch’s patients spoke or wrote to him in their own words, and the survival in his publications of their vivid and varied figures of speech suggests that he respected their terminologies. They were allowed to construct their own body histories, to connect immediately presenting symptoms with medical and emotional occurrences which preceded them by many years. They also maintained a considerable degree of autonomy and privacy in their dealings with him, often communicating by writing or through third parties; neither personal questioning nor physical examination was considered necessary to the consulting process.

Duden’s picture of 18th-century German medical practice is in large part built up by means of a set of contrasts with what she considers the defining features of 19th-century clinical medicine, with frequent reference to changes which are just on the horizon. With ‘the birth of the clinic’, the increase in surgical intervention, the rise of statistical enquiry, the body is about to become objectified and divested of symbolic meaning. Gender will become a rigid category, polarising human biology. The patient’s own experience of pain will cease to possess either narrative coherence or moral meaning, and dialogue between patient and doctor will be reduced to the latter’s ‘scientific’ and prescriptive discourse. On his deathbed, Storch asked for his cadaver to be dissected; and Duden claims that this final medical decision of his life ‘pointed toward the future and in the direction from which such certainty would come’.

How are such certainties about the 19th and 20th centuries borne out by the other two books under review? For one might argue in the opposite sense to Duden that Storch’s final decision merely encapsulated the paradoxes of his professional life, and that the future would be fertile with similar contradictions and intellectual cohabitations. Certainly Wendy Mitchinson’s study of the professional treatment of women patients in Victorian Canada, based on health manuals, medical textbooks and journals, and patient records from hospitals, mental asylums and dispensaries, does not disappoint the enquirer after archaic survivals. Storch himself could not have faulted the author of an 1865 manual who claimed that any attempt to suppress the onset of menstruation – as by dipping the feet in cold water – could lead to death within hours.

More important, the conclusions which Mitchinson draws from her research lend only qualified support to the characterisation of modern medicine as a project divesting the body of symbolic meaning. It is argued here that in 19th-century medicine and society, gender became an organising principle, and analyses of both physiological facts and social roles were structured around a set of polarities: man was identified with rationality, active energy, and stability, woman with the emotions, with passivity and volatility. Above all, man represented the multifaceted public sphere: man was culture, woman nature.

Tidy as this schema was, it suffered from symbolic overload. The stress on observation and measurement in this period favoured the construction of a physiological norm. Man’s body provided that norm; and woman’s body was seen as a deviation from it. Female physiology was pathologised. The life events which identified woman with nature also identified her with death and disease. Every ‘natural’ development – puberty, menstruation, pregnancy, confinement, lactation, menopause – demonstrated and aggravated an ‘essential’ female frailty, placed women at risk of both physical and mental illness, and made them a danger to themselves and to society at large.

One way out of this conceptual impasse was to blame modern urban civilisation for the apparent failings of the female body, and to locate a simpler way of life, in which women’s ‘natural’ functions had been performed without difficulty, in the relatively recent small-town and rural past: a claim which would surely have made Storch laugh in his grave. Another was to construct a second-order norm for the female body which would come into being, not through nature, but through the doctor, who would impose a golden mean in personal and social behaviour and medical therapeutics. The precariousness of the idea of moderation is well illustrated by discussions of breastfeeding: not to nurse was not ‘natural’; nursing too long caused illness in the mother; nursing for contraceptive purposes was monstrous. In exercising both clinical and normative control, the doctor’s authority was reinforced by new, ‘scientific’ terminologies, which effectively suppressed the narratives of the patient.

Mitchinson does not argue that women were entirely passive partners in these developments, or that they were the only class of patients affected. For example, she finds a lower incidence of obstetric intervention in teaching hospitals than in domiciliary practice; and cautiously infers that the private, fee paying female patient who could exercise more choice in the matter than her hospitalised counterpart, usually the recipient of charity, was demanding an extension of the doctor’s role in childbirth. If it is true that pre-modern patients accepted physical suffering as an unremarkable aspect of the history of their bodies, then Mitchinson’s mothers provide further evidence for the 19th century as the moment when, in Duden’s words, ‘a new bodily dependence on unrealisable professional promises was born’.

Within her field, Mitchinson is unusual in not assuming that men enjoyed a more equal relationship with their doctors than women did, or that questions of their own sexuality were treated as unproblematic in this period. Male patients are necessarily minor characters in her book, but they come centre stage in Lesley Hall’s Hidden Anxieties. This covers discussions of male sexuality in the first half of the present century, and is based on a reading of both practitioner and patient sources – medical journals and advice manuals, and the letters which men in their thousands wrote to the birth control campaigner Marie Stopes after the publication of her Married Love in 1918. The avalanche of correspondence which her work precipitated gives the lie to crude assumptions concerning a phallocentric society which automatically validated and even sanctified heterosexual male drives as they are currently understood.

Hall insists that the ‘double standard’ for male and female sexual morality did not go uncontested in Victorian and Edwardian Britain. The notorious sexlessness (‘ladies don’t move’) which was enjoined upon middle-class women was also enjoined upon men. Moral discipline was invoked against ‘seminal losses’ and debilitating by intense pleasure. ‘Continence’ was a code which applied to both sexes, and within the sacrament of marriage; reproaches could be levelled against the lawful spouse as well as the sinful fornicator or masturbator. Storch’s optimistic belief that nature and healing worked through flux and outlet had been replaced by the concept of the body as a capital asset, in danger of dissipation, which needed to be conserved for essential production processes. It comes as no surprise to read that Stopes’s male correspondents expressed severe anxieties about nocturnal emissions and premature ejaculation, and speculated that these were causes of sexual impotence. Unfortunately, the increasing emphasis on the pleasures as well as the duties of marriage in the 20th century did not always bring them peace of mind.

As Hall makes clear, the majority of the medical profession was embarrassed by discussion of these topics, and reluctant to contemplate sexual disorder in the male. The 19th and 20th centuries’ ‘objectification of the body’ heralded by Duden seems, in practice, to have stopped short at the penis; and the identification of the male body with the norm, as described by Mitchinson, seems to have led to the neglect of certain inconvenient or disagreeable male ‘pathologies’. Prescriptions of champagne, or a diet of oysters and stout, were among the most benign by-products of this professional incompetence and aversion; the failure to institute a routine examination for testicular cancer which, like breast and cervical cancers, kills, was and is perhaps the least benign. Stopes, who did not prescribe nostrums, monkey glands, or therapeutic panaceas, instead offered male (and female) sufferers something few doctors’ surgeries could provide: an attentive hearing to their own problems in their own words and, through her books, a new vocabulary with which husbands and wives could discuss sexual problems.

Of these three writers, only Duden directly addresses the question ‘does the body have a history?’ Curiously, it is not her own book, but Hall’s, which lends support to the theory that perceptions actually have the power to generate physiological reality. At the very least, Hall’s material raises the question as to whether the incidence of premature ejaculation and impotence might not vary from one period to another, and leads us to speculate on the cultural conditions which might shape such physical phenomena. Simply to assert, however, that perceptions generate reality is to cut off the process of historical enquiry before it can begin. There are many interrelated aspects of the broader culture – industrialisation, urbanisation, social mobility, genetics, nutrition, the life cycles of micro-organisms – which merit exploration for the light they throw on the history of the body, on the way we may change its history and hence change ourselves, and hence initiate further changes. But phrases such as ‘the 18th-century body’ or ‘the objectified body’ are as yet, save the mark, only figures of speech. They relate to perceptions, not functions, and imply that there is no distinction to be made between the former and the latter. Taken to extremes, this way of writing will merely replace one form of reification with another.