Fat is a manifest tissue

Physicians have historically walked a fine line between expertise and common sense, between innovation and tradition. If what they said to their patients was unintelligible, they ran the risk of being ignored. If, on the other hand, it was believed that doctors’ knowledge and advice were little different from common sense, what was the point of listening to them? What doctors know and what they can do have changed enormously over the past centuries. So has lay knowledge about health and disease, and it is a truism that much common sense on these matters is now shaped by the pronouncements of medical expertise. In the part of the culture I inhabit it counts as common knowledge that an LDL-cholesterol level over 160 means that you should go easy on the butter and the beef; that a blood-pressure reading higher than 140/90 is a sign that you’ve got to take some tablets and do something about your way of life; and (if you’re a late middle-aged male) that a Prostate Specific Antigen level of more than 2.5 augurs a biopsy and maybe worse. All this is testimony to the medicalisation of the common culture (especially in the United States), and to a vocabulary shared by modern doctors and their more medically literate patients.

Roll back history three centuries and the culture held in common between physicians and those able to afford their services was different. Among the things that a physician might have told you (and that you might very well have seen the point of) were that roasted meats were no good for your atrabilious temperament; that you needed to be bled in the spring when you tended to plethora and your pores were dilated; that frequent intercourse opened the passages and was therefore good for the stone; and that if you had a pain in your cods you should avoid chills. Common sense about these sorts of things did not necessarily have to filter down from medical experts to laity, since such knowledge might be an authentic possession of lay culture.

In early 18th-century Britain no physician positioned himself more precisely on the cusp between common sense and scientific expertise than George Cheyne. Born in Aberdeenshire in 1671, and trained at the rising medical school of Edinburgh, Cheyne in 1702 sought his fortune in the seething medical marketplace of London. The metropolis then was, as Roy Porter has said, ‘a world of quacks’. It was also a world of orthodox medical princes. And sometimes it was hard to tell the difference. The properly credentialled physicians who rode about in their coaches-and-six, and lashed out at the unprincipled commercial competition of vulgar ‘empiricks’, often peddled their own proprietary nostrums. The great Dr Richard Mead hawked a rabies powder under his own name; Dr Hans Sloane marketed medicinal chocolate; Dr Nehemiah Grew took out a patent on Epsom Salts.

How to make a medical reputation in such a world? How to make a medical living? A satirist advised the upwardly mobile young London physician ‘to make all the Noise and Bustle you can, to make the whole Town ring of you if possible: So that every one in it may know, that there is in Being, and here in Town too, such a Physician’. One way to make such a noise was to be seen in the fastest and most fashionable medical and literary circles, hoping for a reflected aura, or, at least, for crumbs of patronage to fall from the tables of the great. Within months of his arrival in London, Cheyne secured election to the fastest philosophical club of all, the Royal Society. A great talker, and, at the time, great trencherman and drinker, Cheyne cruised the coffee-houses and taverns, where he ‘found the Bottle-Companions, the younger Gentry, and Free-Livers, to be the most easy of Access, and most quickly susceptible of Friendship and Acquaintance’. As his fellow physician Bernard Mandeville observed, you could with application ‘drink yourself into Practice’.

Another way to make a medical noise had opened up by the late 17th century, and this was conspicuously to challenge common sense through a display of Newtonian science. You could advertise superior curative powers flowing from deeper knowledge of how the human body was constructed and how it worked. The doctor who pretended to know the ultimate structure of the matter that made up your nerves, veins and food also claimed to know much more and much better than mere common sense. Shows of philosophical learning gave proof that he was no mere ‘empirick’. At Edinburgh Cheyne had studied with the one of the great early propagandists for Newtonian medicine, the hard-drinking Jacobite professor Archibald Pitcairne. When Cheyne first arrived in London he had hoped to make a splash with a book offering a new theory of fevers, informed by what he took to be the very sound, and very fashionable, principles of Newtonian mathematics. Aping the Principia, it bristled with postulates, lemmas and scholia, and announced that the human machine ‘is nothing but an Infinity of Branching and Winding Canals, fill’d with Liquors of different Natures’, all to be modelled and understood in the mathematical idiom of micro-mechanism. If you could calculate corpuscular interactions, you could, of course, cure sick bodies.

The great Dr Mead applauded Cheyne’s effort, saying that soon ‘Mathematical Learning will be the Distinguishing Mark of a Physician from a Quack.’ But other philosophically advanced physicians confessed themselves befuddled by Cheyne’s science. Dr Martin Lister admitted that ‘for want of Mathematicks, I could not well enter into some of his reasonings,’ and Cheyne’s book did not quite make the ‘Noise and Bustle’ he had hoped. In 1703 he put his mathematical credentials on the line, publishing a book on the fluxional calculus, and, for his trouble, was savaged by one of Newton’s mathematical bulldogs, who publicised its ‘many errors’.

Two years later Cheyne produced The Philosophical Principles of Natural Religion, an exercise in Newtonian natural theology in the style pioneered by the Reverends Samuel Clarke, Richard Bentley and other pious Boyle Lecturers, but this attempt to appear in the person of a metaphysical moralist was largely ignored. All authors are sad after composition, but finishing a book made Cheyne physically sick. Late in his life, he told Samuel Richardson that ‘I never wrote a Book in my Life but that I had a Fit of Illness after.’ Neglect and bad reviews made his spirits ‘jumbled and turbid’, throwing him into a ‘vertiginous Paroxysm’ so dizzying that he was forced ‘to lay hold on the Posts of my Bed, for fear of tumbling out’. It was, as he was later to realise, an attack of ‘the vapours’, a.k.a. ‘hypochondria’, ‘the Hyp’, ‘melancholia’, ‘the spleen’ – or, in Cheyne’s own famous later formulation, ‘the English malady’. (One of the great puzzles of medical history is figuring out just what early modern people were suffering from when they suffered from ‘the Hyp’ – of the fact of their suffering there can be little doubt – and how their different ways of referring to their condition picked out different states, feelings and visible signs.) Anxious about his future, Cheyne retreated to Scotland to nurse his wounds.

An article of common sense dating from antiquity held that physicians ought to cure themselves: a sick doctor embodied proof of incompetence. Who would willingly consult such a man? Yet at the same time civic sensibilities intermittently expressed a preference for doctors who understood your pain because they had experienced your condition. Thus Montaigne – afflicted with the stone – said that ‘I would prefer to trust a physician who has himself suffered from the malady he would treat.’ Returning from Scotland in 1706, Cheyne began to establish himself as a fashionable physician at Bath, specialising in patients suffering from lowness of spirits and offering predominantly dietary remedies. His expertise in such matters was personal, for Cheyne himself was very depressed and very fat.

In an extraordinary 40-page ‘Case of the Author’ included in The English Malady (1733), Cheyne publicly offered himself both as a warning to the dietetically imprudent and as an advertisement for the curative power of the remedies he had developed. Though he supposed corpulence to have been a family disposition, he identified his first exposure to London high-living as the proximate cause of his extreme obesity. As his weight went up – to a shocking 32 stone – so his spirits went down. To the giddiness induced by professional setbacks were soon added headaches, gut-ache, sores on his legs, liver problems, anxiety, insomnia and a range of other symptoms afflicting both body and mind. Something had to be done.

Desperate diseases traditionally called for desperate remedies, and Cheyne tried most of them: opium, mercury, the Jesuit bark, the waters and even a seton – a thread drawn through a fold in the skin to maintain a discharge of fluids. Taking the Bath and Bristol waters helped a bit, but his condition did not much improve. It was at this point that providence put in Cheyne’s way a clergyman who told him of the therapeutic wonders worked by a total milk diet, and Cheyne determined to try it. As the ‘Aberdeen Falstaff’ rejected the life of excess, so his former ‘Bottle-Companions’ abandoned him, ‘melting away like a Snow-ball in Summer’, and he was left alone to meditate on his way of life and his professional future.

For about twenty-five years he experimented with the ‘low diet’ that best suited his malady, finally settling on a strict ‘Milk and Seed’ regimen, on which, after a time, he became lighter in both mind and body, but any departure from which instantly propelled him back into his former misery. Even before the publication of The English Malady, he talked a lot about his personal version of the protean disorder – a very hip Hyp – then afflicting the fashionable and literary classes. Dr Cheyne had indeed cured himself, and he could cure you, too, if only you would take his advice.

By the 1720s he was publishing that advice: first, an Essay on Gout (which condition bore a family resemblance to the Hyp); later, a tract on Health and Long Life; then The English Malady; and, in the 1740s, towards the end of his life, further works on regimen and therapeutic dietetics. All of these were successful, some spectacularly so. Both Gout and Health went into ten editions by the middle of the century, The English Malady into six editions within six years. Cheyne was not the first writer of blockbuster diet-books – a Venetian named Luigi Cornaro (though not a physician) beat him to it in the 1550s – but he was certainly one of the most influential. Everywhere they talked about Cheyne and his diet. He was favourably quoted in Tom Jones; Samuel Johnson commended his books; John Wesley’s Primitive Physick copied out whole sections of Cheyne’s work; and his patients included Pope, Gay, Beau Nash, Richardson, the Methodist Countess of Huntingdon, Robert Walpole’s adolescent daughter, Catherine (who died under Cheyne’s care of something resembling anorexia nervosa), and the Earl of Chesterfield (who passed Cheyne’s advice ineffectively on to his ‘dear boy’). Cheyne’s dietary advice was pervasive in 18th-century Britain, and, for that reason alone, it’s odd that Anita Guerrini’s fine book is the first attempt at a full-scale biography.

What accounted for Cheyne’s success? His evident sympathy for those suffering from depression – male and female – probably had a lot to do with it, and in this connection the theatre of sincerity which was ‘The Case of the Author’ must have been compelling. But there is something of more general significance in the ambiguity of his medical advice and in the way in which it oscillated between the worlds of expertise and common sense.

Cheyne’s dietetic programme did not wholly abandon his earlier Newtonian idiom. Practical advice about what you should eat to alleviate the English malady, or any other ailment, continued to be justified by displays of knowledge about the ultimate constituents of your body and your food. For example, when Cheyne told you to avoid roast beef, it was not because of a mere empirically observed relation between diet and disease. Rather, expert systems of chemistry and physiology vouched for this advice. In a system bearing a family resemblance to modern views of coronary artery disease, Cheyne recommended that you keep your blood as ‘thin and fluid’ as possible, so that it could flow ‘with the fewest Rubs and least Resistance’. If your blood became ‘viscid, thick, and glewy’, it would deposit a ‘Load of Crust’ on the vessels, causing resistance to the flow. Accordingly, you wanted the corpuscular structure of your food to be very fine. Animal flesh was composed of bulky, hard and angular ‘integral Particles’, liable to gum up the works, while the ‘Fire, Sulphur and volatile Tartars’ of fermented liquors inflamed and corroded the vessels and nerves. By contrast, pure water, sweet cow-whey, light vegetables and grains were all ultimately composed of corpuscles so small, elastic and smoothly shaped that they made no obstruction to fluid flow. Of all this, Cheyne assured any sceptical readers, ‘None can have any Doubt, that has the least Acquaintance with natural Philosophy’.

For all Cheyne’s expertise, his practical advice contained much that was as old as the hills: if high-living made you unwell, then try living low for a time. ‘Diseases must be cured by their contraries’: that’s Cheyne, but it’s also Hippocrates. You could get that sort of advice from anyone at all. No need for a fashionable physician; it made a lot of sense. But what Cheyne gave you – should you happen to want it – was a justification for doing the sensible thing that was state-of-the-scientific-art. In exchange for his fee, he offered you a deep understanding of why low-living was the right thing to do, and, indeed, why in general you should trust him. He was an expert.

A similar ambiguity centred on the overall texture of Cheyne’s dietetics. Good common sense and the good doctor concurred in this: what you wanted was moderation, temperance, the Golden Mean. Nothing could be more evident than the causal relationship between moderation and good health – or, indeed, between moderation and decent behaviour. Medicine and everyday moral sensibilities coincided on this point: gluttony, like undue asceticism, was both bad for you and bad. Yet Cheyne’s counsel was more complicated than that. If you were in good health, and were an ordinary person, then moderation was just fine. But, as an expert physician, Cheyne would be the judge of whether you were in fact healthy or in imminent danger of becoming seriously ill. And if he concluded that you were sicker than you thought, then desperate remedies were vigorously prescribed. So a ‘milk and seed’ diet was not recommended to everyone – and here Cheyne basked in the glow of common sense – but its full rigours were imposed on the valetudinarian and on those who had not realised how sick they were until Cheyne told them. That is why he fought a constant battle with some of his patients to get them to stick with their miserable lowering diets.

Moreover, Cheyne – like prosperous 18th-century Englishmen in general – sometimes displayed a notably liberal sensibility towards the meaning of moderation. You could be persuaded that your diet was moderate, or even low, while living quite high by early 21st-century faddish standards. Cheyne advised Richardson, ‘a staunch Epicure’ whom he considered to be really ill, to take a daily ration of ‘Half a Chicken in Quantity of any fresh tender Meat (any Things else to fill Chinks you please)’, plus maybe 12 ounces of bread, and half a pint of wine. Cheyne himself, even during what he regarded as a light lowering phase, knocked back four ounces of port a day, or ‘not above a Quart, or three Pints at most’ of wine. Moderate exercise was also very good. Richardson, who hated exercise, was exhorted to ride on his hobby horse. Cheyne said he did it himself for an hour every morning, and found ‘great Benefit’ from it.

Cheyne gauged his advice according to varying human natures. Rough and generous food was suitable for rough people: it gave them strength and, anyway, their systems were used to it. He did not write for them; rather, he was concerned with ‘the Valetudinary, the Sedentary, and the Studious’. Their ‘springy, lively, and elastick Fibres’ endowed them with superior sensibility and mental agility, but also laid them open to the longueurs of melancholy. A special and severe dietetics was required to treat those suffering from the English malady: refined and meagre food for refined and delicate people.

Dietetics, and the dispensation of expert advice, became part of a system of cultural display. While the dietetic golden mean reeked of common sense, asceticism, too, had its special appeal. You and Cheyne could jointly decide that you were a person of exquisite sensibility, and that sensibility could be publicly vouched for by the low diet to which you submitted.

The cohabitation of the medical and moral lasted from antiquity well into the 19th century. At any time in this period a physician might seek to cure sick bodies by urging people rationally to control not just their diets but also their emotions and thoughts. Thus Cheyne wrote of the curative powers of Christian faith: ‘The Love of God, as it is the sovereign Remedy of all Miseries, so, in particular, it effectually prevents all the Bodily Disorders the Passions introduce, [and] becomes the most powerful of all the Means of Health and Long Life.’ Guerrini works hard to link him with a special brand of mysticism flourishing in the North-East of Scotland, but takes too many conjectural leaps to make the claim wholly convincing. Such sensibilities were not at all particular to Cheyne. He gave them an idiosyncratic turn but the curative power of religious serenity, like the commendation of dietary temperance, was an early 18th-century commonplace.

Writing a biography of George Cheyne presents difficult problems. Guerrini has done a superb job of scouring the archives for additional scraps of information, and, as a leading scholar of early 18th-century scientific medicine, she fills in some remaining blanks with pertinent details about Cheyne’s associates and his cultural background. Even so, much about his life is still opaque. Practically nothing can be learned about his domestic life (respectable wife, three children), and one would give a lot to know what it was like to be his cook. The primary source remains his autobiographical essay. That in itself isn’t an unusual state of affairs for the period. Yet this autobiography has a remarkable character. It is a medical case history, but a case history in which the author appears as both subject and object, in which his body suffers and is cured through rational acts of will, a therapeutic success story and a moral progress, a dietetic project of the self.

It speaks from a culture in which it was possible to talk in the same idiom, as Guerrini nicely puts it, about ‘the triangle of food, flesh, and spirit’, and in which medicine addressed all three but did not own the exclusive rights to talk intelligibly about any one of them. The voice of medical expertise struggled with that of common sense, but, in order to be authoritative, had to come to some accommodation with lay knowledge and sensibilities. It was also a world in which common sense could still talk back. It could find the prescriptions of medical expertise self-indulgent, as when Johnson warned Boswell: ‘Read Cheyne’s English Malady; but do not let him teach you a foolish notion that melancholy is a proof of acuteness.’ Or it could just find the whole idea of apparently healthy people subsisting on milk and bread very funny indeed:

Suppose we own that milk is good,
And say the same for grass;
The one for babes is only food,
The other for an ass.

Doctor! one new prescription try,
(A friend’s advice forgive;)
Eat grass, reduce thyself, and die;
Thy patients then may live.