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MAKING SENSE OF SICKNESS
Though prehistoric hunting and gathering groups largely escaped epidemics, individuals got sick. Comparison with similar groups today, for instance the Kalahari bush people, suggests they would have managed their health collectively, without experts. A case of illness or debility directly affected the well-being of the band: a sick or lame person is a serious handicap to a group on the move; hence healing rituals or treatment would be a public matter rather than (as Western medicine has come to see them) private.
Anthropologists sometimes posit two contrasting ‘sick roles’: one in which the sick person is treated as a child, fed and protected during illness or incapacity; the other in which the sufferer either leaves the group or is abandoned or, as with lepers in medieval Europe, ritually expelled, becoming culturally ‘dead’ before they are biologically dead. Hunter-gatherer bands were more likely to abandon their sick than to succour them.
With population rise, agriculture, and the emergence of epidemics, new medical beliefs and practices arose, reflecting growing economic, political and social complexities. Communities developed hierarchical systems, identified by wealth, power and prestige. With an emergent division of labour, medical expertise became the métier of particular individuals. Although the family remained the first line of defence against illness, it was bolstered by medicine men, diviners, witch-smellers and shamans, and in due course by herbalists, birth-attendants, bone-setters, barber-surgeons and healer-priests. When that first happened we cannot be sure. Cave paintings found in France, some 17,000 years old, contain images of men masked in animal heads, performing ritual dances; these may be the oldest surviving images of medicine-men.
Highly distinctive was the shaman. On first encountering such folk healers, westerners denounced them as impostors. In 1763 the Scottish surgeon John Bell (1691–1780) described the ‘charming sessions’ he witnessed in southern Siberia:
[the shaman] turned and distorted his body into many different postures, till, at last, he wrought himself up to such a degree of fury that he foamed at the mouth, and his eyes looked red and staring. He now started up on his legs, and fell a dancing, like one distracted, till he trod out the fire with his bare feet.
These unnatural motions were, by the vulgar, attributed to the operations of a divinity … He now performed several legerdemain tricks; such as stabbing himself with a knife, and bringing it up at his mouth, running himself through with a sword and many others too trifling to mention.
This Calvinist Scot was not going to be taken in by Asiatic savages: ‘nothing is more evident than that these shamans are a parcel of jugglers, who impose on the ignorant and credulous vulgar.’ Such a reaction is arrogantly ethnocentric: although shamans perform magical acts, including deliberate deceptions, they are neither fakes nor mad. Common in native American culture as well as Asia, the shaman combined the roles of healer, sorcerer, seer, educator and priest, and was believed to possess god-given powers to heal the sick and to ensure fertility, a good harvest or a successful hunt. His main healing techniques have been categorized as contagious magic (destruction of enemies, through such means as the use of effigies) and direct magic, involving rituals to prevent disease, fetishes, amulets (to protect against black magic), and talismans (for good luck).
In 1912 Sir Baldwin Spencer (1860–1929) and F.J. Gillen (1856–1912) described the practices of the aborigine medicine-man in Central Australia:
In ordinary cases the patient lies down, while the medicine man bends over him and sucks vigorously at the part of the body affected, spitting out every now and then pieces of wood, bone or stone, the presence of which is believed to be causing the injury and pain. This suction is one of the most characteristic features of native medical treatment, as pain in any part of the body is always attributed to the presence of some foreign body that must be removed.
Stone-sucking is a symbolic act. As the foreign body had been introduced into the body of the sick man by a magical route, it had to be removed in like manner. For the medicine-man, the foreign body in his mouth attracts the foreign body in the patient.
As such specialist healers emerged, and as labour power grew more valuable in structured agricultural and commercial societies, the appropriate ‘sick role’ shifted from abandonment to one modelled on child care. The exhausting physical labour required of farm workers encouraged medicines that would give strength; hence, together with drugs to relieve fevers, dysentery and pain, demand grew for stimulants and tonics such as tobacco, coca, opium and alcohol.
In hierarchical societies like Assyria or the Egypt of the pharaohs, with their military – political elites, illness became unequally distributed and thus the subject of moral, religious and political teachings and judgments. Its meanings needed to be explained. Social stratification meanwhile offered fresh scope for enterprising healers; demand for medicines grew; social development created new forms of healing as well as of faith, ritual and worship; sickness needed to be rationalized and theorized. In short, with settlement and literacy, conditions were ripe for the development of medicine as a belief-system and an occupation.
APPROACHES TO HEALING
Like earthquakes, floods, droughts and other natural disasters, illness colours experiences, outlooks and feelings. It produces pain, suffering and fear, threatens the individual and the community, and raises the spectre of that mystery of mysteries – death. Small wonder impassioned and contested responses to sickness have emerged: notions of blame and shame, appeasement and propitiation, and teachings about care and therapeutics. Since sickness raises profound anxieties, medicine develops alongside religion, magic and social ritual. Nor is this true only of ‘primitive’ societies; from Job to the novels of Thomas Mann, the experience of sickness, ageing and death shapes the sense of the self and the human condition at large. AIDS has reminded us (were we in danger of forgetting) of the poignancy of sickness in the heyday of life.
Different sorts of sickness beliefs took shape. Medical ethnologists commonly suggest a basic divide: natural causation theories, which view illness as a result of ordinary activities that have gone wrong – for example, the effects of climate, hunger, fatigue, accidents, wounds or parasites; and personal or supernatural causation beliefs, which regard illness as harm wreaked by a human or superhuman agency. Typically, the latter is deliberately inflicted (as by a sorcerer) through magical devices, words or rituals; but it may be unintentional, arising out of an innate capacity for evil, such as that possessed by witches. Pollution from an ‘unclean’ person – commonly a corpse or a menstruating woman – may thus produce illness. Early beliefs ascribed special prominence to social or supernatural causes; illness was thus injury, and was linked with aggression.
This book focuses mostly upon the naturalistic notions of disease developed by and since the Greeks, but mention should be made of the supernatural ideas prominent in non-literate societies and present elsewhere. Such ideas are often subdivided by scholars into three categories: mystical, in which illness is the automatic consequence of an act or experience; animistic, in which the illness-causing agent is a personal supernatural being; and magical, where a malicious human being uses secret means to make someone sick. The distribution of these beliefs varies. Africa abounds in theories of mystical retribution, in which broken taboos are to blame; ancestors are commonly blamed for sickness. Witchcraft, the evil eye and divine retribution are frequently used to explain illness in India, as they were in educated Europe up to the seventeenth century, and in peasant parts beyond that time.
Animistic or volitional illness theories take various forms. Some blame objects for illness – articles which are taboo, polluting or dangerous, like the planets within astrology. Other beliefs blame people – sorcerers or witches. Sorcerers are commonly thought to have shot some illness-causing object into the victim, thus enabling healers to ‘extract’ it via spectacular rituals. The search for a witch may involve divination or public witch-hunts, with cathartic consequences for the community and calamity for the scapegoat, who may be punished or killed. Under such conditions, illness plays a key part in a community’s collective life, liable to disrupt it and lead to persecutions, in which witchfinders and medicine men assume a key role.
There are also systems that hinge on spirits – and the recovery of lost souls. The spirits of the dead, or nature spirits like wood demons, are believed to attack the sick; or the patient’s own soul may go missing. By contrast to witchcraft, these notions of indirect causation allow for more nuanced explanations of the social troubles believed to cause illness; there need be no single scapegoat, and purification may be more general. Shamanistic healers will use their familiarity with worlds beyond to grasp through divination the invisible causes behind illness. Some groups use divining apparatus – shells, bones or entrails; a question will be put to an oracle and its answer interpreted. Other techniques draw on possession or trance to fathom the cause of sickness.
Responses to sickness may take many forms. They may simply involve the sick person hiding away on his own, debasing himself with dirt and awaiting his fate. More active therapies embrace two main techniques – herbs and rituals. Medicines are either tonics to strengthen the patient or ‘poisons’ to drive off the aggressor. Choice of the right herbal remedy depends on the symbolic properties of the plant and on its empirical effects. Some are chosen for their material properties, others for their colour, shape or resonances within broader webs of symbolic meaning. But if herbs may be symbolic, they may also be effective; after much pooh-poohing of ‘primitive medicine’, pharmacologists studying ethnobotany now acknowledge that such lore provided healers with effective analgesics, anaesthetics, emetics, purgatives, diuretics, narcotics, cathartics, febrifuges, contraceptives and abortifacients. From the herbs traditionally in use, modern medicine has derived such substances as salicylic acid, ipecac, quinine, cocaine, colchicine, ephedrine, digitalis, ergot, and other drugs besides.
Medicines are not necessarily taken only by the patient, for therapy is communal and in traditional healing it is the community that is being put to rights, the patient being simply the stand-in. Certain healing rituals are rites de passage, with phases of casting out and reincorporation; others are dramas; and often the patient is being freed from unseen forces (exorcism). Some rituals wash a person clean; others use smoke to drive harm out. A related approach, Dreckapotheke, involves dosing the patient with disgusting decoctions or fumigations featuring excrement, noxious insects, and so forth, which drive the demons away.
A great variety of healing methods employ roots and leaves in elaborate magical rituals, and all communities practise surgery of some sort. Many tribes have used skin scarifications as a form of protection. Other kinds of body decoration, clitoridectomies and circumcision are common (circumcision was performed in Egypt from around 2000 BC). To combat bleeding, traditional surgeons used tourniquets or cauterization, or packed the wound with absorbent materials and bandaged it. The Masai in East Africa amputate fractured limbs, but medical amputation has been rare. There is archaeological evidence, however, from as far apart as France, South America and the Pacific that as early as 5000 BC trephining was performed, which involved cutting a small hole in the skull. Flint cutting tools were used to scrape away portions of the cranium, presumably to deliver sufferers from some devil tormenting the soul. Much skill was required and callous formations on the edges of the bony hole show that many of the patients survived.
BODY LORE
Illness is thus not just biological but social, and concepts of the body and its sicknesses draw upon powerful dichotomies: nature and culture, the sacred and the profane, the raw and the cooked. Body concepts incorporate beliefs about the body politic at large; communities with rigid caste and rank systems thus tend to prescribe rigid rules about bodily comportment. What is considered normal health and what constitutes sickness or impairment are negotiable, and the conventions vary from community to community and within subdivisions of societies, dependent upon class, gender and other factors. Maladies carry different moral charges. ‘Sick roles’ may range from utter stigmatization (common with leprosy, because it is so disfiguring) to the notion that the sick person is special or semi-sacred (the holy fool or the divine epileptic). An ailment can be a rite de passage, a childhood illness an essential preliminary to entry into adulthood.
Death affords a good instance of the scope for different interpretations in the light of different criteria. The nature of ‘physical’ death is highly negotiable; in recent times western tests have shifted from cessation of spontaneous breathing to ‘brain death’. This involves more than the matter of a truer definition: it corresponds with western values (which prize the brain) and squares with the capacities of hospital technology. Some cultures think of death as a sudden happening, others regard dying as a process advancing from the moment of birth and continuing beyond the grave. Bodies are thus languages as well as envelopes of flesh; and sick bodies have eloquent messages for society.
It became common wisdom in the West from around 1800 that the medicine of Orientals and ‘savages’ was mere mumbo-jumbo, and had to be superseded. Medical missions moved into the colonies alongside their religious brethren, followed in due course by the massive health programmes of the modern international aid organizations. By all such means Europeans and Americans sought to stamp out indigenous practices and beliefs, from the African witchdoctors and spirit mediums to the vaidyas and hakims of Hindu and Islamic medicine in Asia. Native practices were grounded in superstition and were perilous to boot; colonial authorities moved in to prohibit practices and cults which they saw as medically, religiously or politically objectionable, thereby becoming arbiters of ‘good’ and ‘bad’ medicine. Western medicine grew aggressive, convinced of its unique scientific basis and superior therapeutic powers.
This paralleled prejudices developing towards folk or religious medicine within Europe itself. The sixteenth-century French physician Laurent Joubert (1529–83) wrote a huge tome exposing ‘common fallacies’. Erreurs populaires [1578] systematically denounced the ‘vulgar errors’ and erroneous sayings of popular medicine regarding pregnancy, childbirth, lying-in, infant care, children’s diseases and so forth, insisting that ‘such errors can be most harmful to man’s health and even his life’. ‘Sometimes babies, boys as well as girls, are born with red marks on their faces, necks, shoulders or other parts of the body,’ Joubert noted. ‘It is said that this is because they were conceived while their mother had her period … But I believe that it is impossible that a woman should conceive during her menstrual flow.’ Another superstition was that whatever was imprinted upon the imagination of the mother at the time of conception would leave a mark on the body of her baby.
Elite medicine sought to discredit health folklore, but popular medicine has by no means always been misguided or erroneous. Recent pharmacological investigations have demonstrated the efficacy of many traditional cures. It is now known, for instance, that numerous herbal decoctions – involving rue, savin, wormwood, pennyroyal and juniper – traditionally used by women to regulate fertility have some efficacy. Today’s ‘green pharmacy’ aims at the recovery of ancient popular medical lore, putting it to the scientific test.
Once popular medicine had effectively been defeated and no longer posed a threat, scholarly interest in it grew, and great collections of ‘medical folklore’ and ‘medical magic’, stressing their quaintness, were published in the nineteenth century. But it is a gross mistake to view folk medicine as a sack of bizarre beliefs and weird and wonderful remedies. Popular medicine is based upon coherent conceptions of the body and of nature, rooted in rural society. Different body parts are generally represented as linked to the cosmos; health is conceived as a state of precarious equilibrium among components in a fluid system of relations; and healing mainly consists of re-establishing this balance when lost. Such medical beliefs depend on notions of opposites and similars. For example, to stop a headache judged to emanate from excessive heat, cold baths to the feet might be recommended; or to cure sciatica, an incision to the ear might be made on the side opposite to the pain.
Traditional medicine views the body as the centre or the epitome of the universe, with manifold sympathies linking mankind and the natural environment. Analogy and signatures are recurrent organizing principles in popular medicine. By their properties (colour, form, smell, heat, humidity, and so on) the elements of nature signal their meaningful associations with the human body, well and sick. For instance, in most traditional medicine systems, red is used to cure disorders connected with blood; geranium or oil of St John’s wort are used against cuts. Yellow plants such as saffron crocus (Crocus sativus) were chosen for jaundice, or the white spots on the leaves of lungwort (Pulmonaria officinalis) showed that the plant was good for lung disease, and so on. Sometimes it was argued that remedies had been put in places convenient for people to use. So, in England, the bark of the white willow (Salix alba) was valued for agues, because the tree grows in moist or wet soil, where agues chiefly abound, as the Revd Edmund Stone, of Chipping Norton in Oxfordshire, observed in his report to the Royal Society of London in 1763:
the general maxim, that many natural maladies carry their cures along with them, or that their remedies lie not far from their causes, was so very apposite to this particular case, that I could not help applying it; and that this might be the intention of Providence here, I must own had some little weight with me.
Maintaining health required understanding one’s body. This was both a simple matter (pain was directly experienced) and appallingly difficult, for the body’s interior was hidden. Unable to peer inside, popular wisdom relied upon analogy, drawing inferences from the natural world. Domestic life gave clues for body processes – food simmering on the hob became a natural symbol for its processing in the stomach – while magic, folksong and fable explained how conception and birth, growth, decay and death mirrored the seedtime and the harvest. The landscape contained natural signs: thus peasant women made fertility shrines out of springs. To fathom abnormalities and heal ailments, countryfolk drew upon the suggestive qualities of strange creatures like toads and snakes (their distinctive habits like hibernation or shedding skins implied a special command over life and death), and also the evocative profiles of landscape features like valleys and caves, while the phases of the moon so obviously correlated with the menstrual cycle.
Nature prompted the idea that the healthy body had to flow. In an agrarian society preoccupied with the weather and with the changes of the seasons, the systems operating beneath the skin were intuitively understood as fluid: digestion, fertilization, growth, expulsion. Not structures but processes counted. In vernacular and learned medicine alike, maladies were thought to migrate round the body, probing weak spots and, like marauding bands, most perilous when they targeted central zones. Therapeutics, it was argued, should counter-attack by forcing or luring ailments to the extremities, like the feet, where they might be expelled as blood, pus or scabs. In such a way of seeing, a gouty foot might even be a sign of health, since the big toe typically afflicted was an extremity far distant from the vital organs: a foe in the toe was trouble made to keep its distance.
In traditional medicine, as I have said, health is a state of precarious balance – being threatened, toppled and restored – between the body, the universe and society. More important than curing is the aim of preventing imbalance from occurring in the first place. Equilibrium is to be achieved by avoiding excess and pursuing moderation. Prevention lies in living in accord with nature, in harmony with the seasons and elements and the supernatural powers that haunt the landscape: purge the body in spring to clean it of corrupt humours, in summer avoid activities or foods which are too heating. Another preventative is good diet – an idea encapsulated in the later advice, ‘an apple a day keeps the doctor away’. Foods should be consumed which give strength and assimilate natural products which, resembling the body, are beneficial to it, such as wine and red meat: ‘meat makes flesh and wine makes blood’, runs a French proverb. The idea that life is in the blood is an old one. ‘Epileptic patients are in the habit of drinking the blood even of gladiators,’ noted the Roman author Pliny (AD C. 23–79): ‘these persons, forsooth, consider it a most effectual cure for their disease, to quaff the warm, breathing, blood from man himself, and, as they apply their mouth to the wound, to draw forth his very life.’
Clear-cut distinctions have frequently been drawn between ‘science’ and ‘superstition’ but, as historians of popular culture today insist, in societies with both a popular and an elite tradition (high and low, or learned and oral cultures), there has always been complex two-way cultural traffic in knowledge, or more properly a continuum. While often aloof and dismissive, professional medicine has borrowed extensively from the folk tradition.
Take, for instance, smallpox inoculation. There had long been some folk awareness in Europe of the immunizing properties of a dose of smallpox, but it was not until around 1700 that this knowledge was turned to use. The first account of artificial inoculation was published in the Philosophical Transactions of the Royal Society of London in 1714, and widespread publicity was achieved thanks to the observations of Lady Mary Wortley Montagu (1689–1762), wife of the British consul in Constantinople, that Turkish peasant women routinely performed inoculations. One English country doctor who practised inoculation was Edward Jenner. In his native Gloucestershire it was also known in the farming community that there was a disease of cattle – cowpox – which was occasionally contracted by human beings, particularly dairy-maids who milked the cows. This led Jenner to the idea behind vaccination; elite medicine clearly had much to learn from folk tradition.
We must thus avoid taking for granted the antagonistic presence of two distinct traditions: the scientific and the superstitious, the right and the wrong. In all complex societies there have been various ways of thinking about the body, health and disease. In early modern Europe there was nothing mutually exclusive about different types of therapeutics or styles of healing. The English parson-physician, Richard Napier (1559–1634), was a graduate of Oxford University and a learned scholar. Yet he was also an exponent of religious healing: he would pray for the recovery of his patients, and to protect them ‘against evil spirits, fairies, witcheries’ he would also give them protective sigils and amulets to wear, as well as purges. And when the diarist Samuel Pepys (1633 – 1703), who later became president of the Royal Society of London, surveyed his health and found himself in exceptionally good condition, he was unsure of the cause. On 31 December 1664, he balanced his books for the year:
So ends the old year, I bless God with great joy to me; not only from my having made so good a year of profit, as having spent £420. and laid up £540 and upward.
But I bless God, I never have been in so good plight as to my health in so very cold weather as this is, nor indeed in any hot weather these ten years, as I am at this day and have been these four or five months. But I am at a great loss to know whether it be my Hare’s fote, or taking every morning a pill of Turpentine, or my having left off the wearing of a gowne.
As this suggests, for Pepys as for others, religion, magic and medicine coalesced for therapeutic ends. Bread baked on Good Friday would never go mouldy; if stored, it would treat all manner of disease; rings made out of silver collected at the Eucharist would cure convulsions; the sacrament of confirmation would ward off sickness. Such beliefs had been encouraged within the proliferating healing rites of medieval Catholicism. In Protestant countries, with the anathematizing of pilgrimages, relics, holy waters, invocation of saints and the like at the Reformation, similar rituals continued, though essentially without express ecclesiastical authorization.
Medical magic was accepted by the unlettered and the elite alike until at least the seventeenth century, and was thought to operate in many ways. Disease could be transferred, transplanted or transformed. A sick person should boil eggs in his own urine and then bury them; as the ants ate them, the disease would also be eaten up. To heal a swollen neck, one was to draw a snake along it, put the snake in a tightly corked bottle and bury it; as the snake decayed, the swelling would go. Similarly, whooping cough sufferers should stand on the beach at high tide; when the tide went out, it carried the cough with it. Warts might be treated by touching them with a pebble; the pebbles were placed in a bag which was ‘lost’ as the sufferer went to church. Whoever found the bag acquired the warts too.
It was also widely believed that disease could be transferred to the dead. The sick person should clutch a limb of someone awaiting burial; the disease would then leave his or her body and enter the corpse. This mode of magic explains why mothers crowded around a scaffold, struggling to get their sickly infants into contact with an executed felon’s body.
The doctrine of signatures linking humans and nature, microcosm and macrocosm, was of course interwoven with astrology – a learned science as well as a popular belief. Understanding of the heavens was seen as providing the key to the particular properties of herbs and minerals. Plants governed by Venus, herbalists explained, were aids to fertility and childbirth; those under Mars provided strength, and the moon played a crucial part.
Above all, magic functioned with religion in popular healing. Christianity endorsed an articulate symbolic cosmology which asserted the supreme potency of non-material forces. Roman Catholicism etched onto believers’ minds the notion of miracle cures and the healing powers of sacraments, relics, Latin incantations, invocation of saints and holy waters. Popular therapeutic magic and religious healing could be interchangeable. Rejecting Catholic ‘superstition’, Protestants fought such ‘contamination’ of religion with magic; but the Reformation’s iconoclasm towards magic within the Church encouraged it to flourish in a kind of ‘black market’ outside. Modernizing forces – literacy, the availability of commercial medicines, the rise of the medical profession – gradually peripheralized such beliefs. But the finger of God might continue to be seen in visitations of illness and injury. ‘Last Wednesday night while carrying a bucket of water from the well,’ noted the Revd Francis Kilvert (1840–79) in his journal on 26 December 1874, ‘Hannah Williams slipped upon the icy path and fell heavily upon her back. We fear her spine was injured for though she suffers acute pain in her legs she cannot move them. The poor wild beautiful girl is stopped in her wildness at last, and perhaps by the finger of God.’
What must be stressed is the ceaseless dialectic of popular and educated medicine, and everything between. Superficially at least, the distinctive medical systems seem to have nothing in common but animosity. The medical missionary and explorer, David Livingstone (1813 – 73), recorded an exchange between representatives of quite different medical systems:
MEDICAL DOCTOR: Hail, friend! How very many medicines you have about you this morning! Why, you have every medicine in the country here.
RAIN DOCTOR: Very true, my friend; and I ought; for the whole country needs the rain which I am making.
M.D: So you really believe that you can command the clouds? I think that can be done by God alone.
R.D: We both believe the very same thing. It is God that makes the rain, but I pray to him by means of these medicines, and, the rain coming, of course it is then mine.
As the Rain Doctor recognized, they had more in common than met the eye. And the similarities yet differences between diverse medical systems and practices have always been evident to the sick themselves. In modern Taiwan, for instance, the sick use modern western doctors for certain ailments, traditional Chinese medicine for others, Japanese medicine and local herbal medicine and healers.
