This work originated from an interest in the history of ideas in medicine. I wanted to find out why our forefathers, almost to a man, believed that the proper way to treat most diseases was to remove blood from the patient, and as there was to my knowledge no published translation of Galen's three bloodletting works in any modern language, I made one from the Greek of Kühn's edition, and went on to consider where his ideas came from and how they developed in the course of a long and active life. The material was used in 1978 as a dissertation for the degree of M.A. in classics from the University of Natal. Subsequently the translations have been revised, and the discussion rewritten to make it more accessible to the general reader. An introductory chapter on Galen's system of pathology, based on subsequent reading, has been added, and the passages quoted in the text in Greek and in modern languages other than English have been translated. Although unfamiliar old terms are explained when first encountered, they have all been collected into a glossary for easy reference, together with such modern technical terms as may be unfamiliar to the non-specialist.

Kühn's text is corrupt in many places, and only one of the three works has had any critical attention. I have therefore examined a number of the manuscripts and early printed editions, which clear up some of the difficulties. I must make it clear, however, that the only aim has been to improve the translations, not to establish texts; I am not a philologist, even by inclination.

The dating of the three works will be considered later, but it is clear that the first work, the De Venae Sectione adversus Erasistratum, was composed soon after Galen's first arrival in Rome; it is representative, therefore, of his youthful opinions. There is nothing in this work to suggest that Galen, at that stage of his life, considered using any evacuant remedy other than phlebotomy at the onset of the patient's illness. He agrees with Erasistratus that it is necessary to empty the plethos; the only question is by what means it should be evacuated. ‘I have always thought that once evacuation has been agreed on, the easiest and most prompt remedy is to open a vein, since in this way the inflammatory matters, and these alone, are evacuated as quickly as possible.’ All patients with plethos, he says, are most quickly and effectively treated by opening the veins; although Galen mentions alternative remedies used by Erasistratus, there is no indication that he uses any of them himself in these circumstances. Not only the physicians of the rationalist sect, but also the empiricists, all use venesection; even Asclepiades, who condemned all the dogmas of his predecessors and described the Hippocratic methods as an exercise in death. It is in use in most diseases and the most acute, and Hippocrates himself, ‘whom we regard as the leader of all the distinguished men in the profession, and the other men of old clearly did use it’. The ancients, in Galen's opinion, thought it nothing less than the most effective of all remedies.

At the beginning of his first work on venesection Galen expresses his surprise that Erasistratus, a man so punctilious in matters of detail, should have mentioned venesection only once in all his works, and at that only in passing; for, says Galen, it is a remedy of such strength and efficacy that it was regarded by the ancients as nothing less than the most effective of all. It is made clear later that the ancients to whom he refers are, in fact, Erasistratus' predecessors in the profession, including Hippocrates; Galen frequently mentions Hippocrates' use of the remedy in this work, observing that he employed it in most diseases and in the most acute, and that even Asclepiades, who rejected almost all the other methods of Hippocrates, nevertheless still made use of venesection. In another work Galen maintains that venesection has been dealt with very completely by Hippocrates. He is not alone in this opinion. Littré observes: ‘When we enquire which remedies, among the many that were used, are most frequently mentioned as having been applied, we find that bloodletting and the evacuants – emetics and, in particular, purgatives – play the principal role in the therapy of the Hippocratic physicians, and hence of Hippocrates himself.’ Adams expresses a similar opinion in his commentary on Paulus Aegineta. ‘We have had occasion frequently to remark’, he says, ‘that Hippocrates practised venesection freely in various diseases. He has left no treatise, however, expressly on the subject.’

The impression conveyed by both these nineteenth-century writers, and by Galen himself, is that the Hippocratic writers frequently mentioned venesection, and used it freely.

Those who intend to use phlebotomy must consider first of all how many states of the body there are that call for evacuation. The next question is, which of these states require evacuation by phlebotomy; for there are many conditions, some of which need some other sort of evacuation, and certainly not bloodletting. The third problem is to decide which patients can stand the evacuation without harm, since sometimes the patient's condition demands phlebotomy, yet he cannot bear it either because of his stage of life, or the season of the year, or the nature of the country, or because of some disorder of the mouth of the belly. (This is often miscalled the stomach; in the interests of brevity, however, I shall nevertheless use the term from now on in the whole of this work). There are also some who cannot bear phlebotomy because of their general habit of body, even though by reason of their disease they need it very much. If we are to draw such distinctions, we must consider each occasion on its merits, just as we do with any other remedy. Our next question concerns the veins that are to be opened, since extensive research has been undertaken to decide whether it makes no difference which vein one chooses to cut, all being equally helpful in all conditions, or whether, as Hippocrates and the most celebrated physicians thought, it makes a great deal of difference whether one opens this one rather than that.

In Galen's own time, some proponents of venesection believed that it was immaterial which vein was opened, since the same effect could equally well be obtained by using any of them; others, Galen among them, thought that it made a great deal of difference which vessel was used. Hippocrates and the most celebrated physicians, he says, were of this opinion also. This is not an isolated opinion of Galen's; he expresses it in all three of his works on venesection, and he makes further mention of specific sites for bloodletting in the De Sanitate Tuenda, the De Methodo Medendi, Ad Glauconem de Methodo Medendi, and his commentary on the Aphorisms. Now Galen was an expert anatomist, and his view of the structure (as distinct from the function) of the vascular system was, except in insignificant detail, that of the anatomist of today; yet he approved of practices of revulsive phlebotomy which, it would seem, must be quite inconsistent with such a view of vascular anatomy. To try to understand why he did this it will be necessary to summarise not only his own anatomical opinions, but also those of some of his predecessors, particularly those who offered clear accounts of the peripheral vessels.

Since the vessels contain blood, and since blood has been a subject of interest to man from the earliest times, we find some reference to blood-vessels in the earliest Western literature. Homer describes how Antilochus, leaping on Thoon from behind, cut right through the vein that runs straight along the back till it arrives at the neck.

The value of diaries and correspondence as source materials for many aspects of research has long been appreciated by historians to reveal contemporary information about daily life, fashion, architecture, politics, travel, spiritual reflections, agriculture, industry, weather and even folk-lore. In the past historians with an interest in these categories have used letters and journals as indispensable accounts of attitudes and thoughts, facts, events and personalities not recorded elsewhere, and to support or contradict alternative information. However, these same accounts also contain a substantial amount of material about patients, medical practitioners and contemporary responses to illness and health in a particularly immediate and first hand way. Recovering the medical information from such sources is a slow rather than a difficult procedure, but provides facts and opinions about the patient's illness and health not to be found anywhere else in eighteenth century material. Recent work to reconstruct community life in the past has already shown the value of this new approach in research. The purpose of this essay is to illustrate how fragments from diaries and letters may be considered alongside each other and in relation to other sources to provide a picture of eighteenth century medicine from the recipients' view.

The sufferer's experience of illness, although a relatively recent subject of historical research, is not difficult to investigate. In all ages, people have been fascinated by illness. Thus, diaries and autobiographies are replete with descriptions of the disorders suffered by both writers and their family members, friends and acquaintances. Seventeenth century England was rich in such documents. However, historians who have used these source materials have generally been interested in such subjects as politics, religion, economics and family relationships, leaving the great wealth of medical information they contain virtually untapped.

The extent to which diaries reflect general experience is frequently and deservedly questioned. The seventeenth century diarists whose writings have survived were members of the middle and upper classes. Furthermore, diarists and autobiographers are unusual in any age, feeling a need most people never feel to commit thoughts and experience to paper. Their attitudes and behaviour can be taken as representative neither of general experience nor of the experience of others at their social level.

Nonetheless, such records of unique, personal experience are invaluable to the historian, providing as they literally do, a voice from the grave which can make the past live as no other source can. And the fact that the experiences they describe may not be representative is, perhaps, insignificant, since each individual's experience is to a large extent unique, whether or not he or she describes it in a diary.

Introduction

The first act of the historian, the act which constitutes all the history (s)he subsequently writes, is to decide to write the history of something. That ‘something’ is naturally, normally, taken from the world around us, the world of which the historian is a part. And so it is that in roughly the last hundred years we have had histories of midwifery, of obstetrics, and of their professions – female midwives, male obstetricians. The writing of the histories coincides with the existence of these present realities of which the histories have been written. Such history-writing forms a specimen both of ‘tunnel history’ and of ‘present-centred history’. Equally, and of special concern in the present volume, it is ‘iatrocentric’: that is to say, histories of, say, obstetrics are inevitably written from the viewpoint of the obstetrician. The survival of evidence in handy packages (treatises of obstetrics/midwifery, written mainly by men) conspires with the attitude of the historian to perpetuate this state of affairs. There is an overwhelming tendency to see the story as a technical matter, to dignify the techniques therefore with a special status, and thus to end not only with a whiggish history of inevitable ‘progress’ (the present day being the age of perfected technique), but also with an account which excludes the viewpoint of the very people who must have been at the heart of the story: the women who actually gave birth to our ancestors.

For the nineteenth century the history of English medicine has long since ceased to be written as though it were simply the annals of heroic doctors and epoch-making breakthroughs. That old warhorse, the epic of medical progress, featuring The Revolution in Victorian Medicine and the consequent deliverance (as two recent popular books put it) from The Age of Agony to The Age of Miracles, has for some time now been comprehensively challenged by a variety of alternative ways of seeing.

For example, complementing Ackerknecht's work, the late Michel Foucault argued that The Birth of the Clinic spelt a revolution in ‘medical gaze’, with the new normative and technological order of the hospital entailing fresh diagnostic epistemologies and disease representations, all generating vast medical power. Paralleling and to some degree overlapping with Foucault, many medical sociologists have trained their spotlight on professionalization as the great dynamo of medical transformation. Their timely attention to professional ambitions further reminds us that the Victorian age saw the rise of the public health movement, and other critical encounters in medicine's equivocal relations with the state; and this in turn has implications for what one school of investigators has dubbed the ‘medicalization of life’ – a concept often linked with polemical exposés of the ‘disabling professions’ and ‘the expropriation of health’, and with a radical desire to demystify medicine's allegedly hegemonic role as a secular and naturalizing instrument of ‘social control’. Of course, as ‘medicalization’ proceeded and orthodoxy sandbagged its citadel in the Victorian age, ‘alternative’ medical therapies became steadily more marginalized; and awareness of this polarization has informed recent explorations of radical and plebeian medicine.

Introduction

Not many historians so far have examined Puritan attitudes to physical illness. A lot of the contextual spadework, however, has already been done by social, cultural, political, religious and demographic historians. They provide the larger picture in which to place the subject and they also help to illuminate related issues (for instance, the spiritualisation of life, providence, the different shades of Puritanism, the material conditions of society, etc.). Moreover, thanatology has recently become popular. As death was often the expected consequence of illness in the seventeenth century, people's attitudes to it had a close relationship to their perceptions of illness.

Attitudes to illness itself have been studied by Keith Thomas and Alan Macfarlane. Both bring out the importance of providence as a means by which Puritans made sense of illness. Thomas also provides an influential and important overview of cultural change in seventeenth century England that shows magic declining with a trend towards secularisation after the Restoration. It may be, as Jonathan Barry points out in this volume, that secularisation was not as rapid or as clear-cut as some historians, following Thomas, have imagined. Also, more specifically, the case for providentialism may have been overemphasised, and in this essay I shall spell out in detail the nature of the eclectic use of physical and religious explanations of illness.

Psychological illness in the seventeenth century has received some recent attention.

The fifth Abbasid caliph, Harun al-Rashid, had three wives whose beauty, grace and wit were legendary. At the same time, he also had a short, fat, ugly cook named Murjana. One day, while this Murjana was out in the fields, she came across the body of a dead horse surrounded by wild animals. To her surprise, however, not a single animal would come near the carcass. Murjana decided to investigate. When she reached the body, she found a charm hanging about its neck which she removed forthwith and hung about her own neck. No sooner had she done this than the wild beasts sprang onto the horse and began to devour it. When she reached the palace, her beauty amazed all who saw her, not least the caliph who became so enamoured that he married her at once, neglecting all his other wives. Not long after, poor Murjana sickened and died. The caliph was inconsolable. However, the woman who was washing the body before burial came across the charm. She instantly donned it and was, in her turn, transformed such that, when Harun saw her, he forgot all about Murjana and married her on the spot.

This unhistorical but colourful story formed the substance of a favourite Arabic charm widely used throughout the Levant by the peasants during the early part of this century. It was written on paper and wrapped in cloth and, when worn around the neck, it was supposed to confer the same sort of luck on its wearer as befell Murjana and her successor.

Doing justice to the patient's view is a precarious undertaking because it is a journey to uncharted regions. To help find our bearings, maps for analysis may be borrowed: those histories which have interpreted for us the work of physicians, their knowledge of diseases, or the medical profession's turning towards the hospital as a place wherein patients and their diseases are most efficiently scrutinized. But even if a patient is liable to accept with one part of his mind the medical version of what ails him, many another aspect of illness will turn to haunt the mind and the emotions, and precipitate an interpretation inconsistent with the more or less neat, and therefore also reassuring, pattern of medical analysis, with its diagnostic and prognostic functions.

In attempting a foray into such a land of variations, the only guideline will be the subjective view, the actions and thoughts of individuals as they are faced with suffering and bodily weakness. Subjective reactions are certainly conditioned by society and by personal values which temper what is done or left undone. The quirks of human nature are often most apparent in the face of unknown or dangerous situations. Whether one is stoic, frightened, resigned, disparaging or resolute can be conditioned, or it can be a response which breaks the mould. All it ultimately tells us about is how life was dealt with, but this, in itself, is an aid to interpretation.

In the concluding chapter of Religion and the Decline of Magic Keith Thomas describes the ‘decline of magic’ after 1660, replaced by a range of practical, scientific and medical methods to counter, or at least mitigate, the uncertainties of life, amongst which illness was the most persistent. Historians of medicine have generally endorsed Thomas' view that medical remedies grew in importance in the eighteenth century, at the expense of religious or magical means of healing. In and around the towns at least the qualified medical man replaced the minister as the chief healer, whilst patent medicines, endorsed by medical men, proliferated at the expense of home-made cures. In the key areas of witchcraft and mental illness moral and religious explanations of disease gave way, in official circles at least, to more secular, materialistic accounts. Thomas suggests that such developments resulted in a widening gap between popular and elite notions, as the rural poor clung to their traditional remedies and magical beliefs, now dismissed as vulgar superstitions by the educated.

Thomas and other historians have been more confident in describing this process than in explaining it. Thomas rightly dismisses the notion that medicine or science had decisively demonstrated their superiority, concluding that ‘in medicine as elsewhere, therefore, supernatural theories went out before effective techniques came in’. Thomas is forced to suggest, tentatively, a revolution of aspirations, linked to a new scientific worldview.

We have histories of diseases but not of health, biographies of doctors but not of the sick. Admittedly, in recent years in particular, a barrage of attacks has been mounted against the ways scholars have traditionally conceived the history of medicine. The discipline (critics allege) has been too Whiggish, too scientistic, either deliberately fostering or at least unconsciously underwriting myths of the triumphal cavalcade of scientific medicine. And in response strenuous counter attempts have been made to ‘demystify’ medical history, and to promote research oriented towards new ways of seeing, in particular examining the socio-cultural construction of medical knowledge and medicine's role within wider networks of ideology and power. As yet, however, these winds of change have rarely led to much attention being paid to the objects of medicine, the recipients of ‘the clinical gaze’, the sufferers.

Indeed, perhaps ironically, these new and critical forays into medical history often end up by silently reinforcing that old stereotype of the sick, i.e. their basic invisibility. Traditional history of medicine simply ignored the patient. After all, it was what the doctor did to, and for, the sick that counted; the patient was just the raw material, the unwitting bearer of a disease or lesion. After all, no one ever suggested that historians of sculpture should concentrate on slabs of marble. Traditional history of medicine thus ignored the patient: he or she was of no interest. Modern critical histories, by contrast, still ignore the patient but often by design; for they sometimes argue (as has David Armstrong, following Foucault) that there can be no such material person as the ‘patient’, directly accessible to the historian.

The publication in 1724 of Richard Mead's Harveian oration of the previous year provoked a vigorous and instructive controversy. Relying largely upon the evidence of a series of coins struck at Smyrna in Asia Minor, Mead argued that doctors in ancient Rome and its empire were men of education and high social standing, worthy precursors of the London College of Physicians. Ancient allegations of incompetence and corruption he referred to the servile practitioners of surgery, not to the physicians. Retribution was not long in coming. Conyers Middleton, theologian, librarian and unstinting controversialist, retorted that, whatever the situation in Greek Smyrna, the doctor in Rome and Italy was often a slave or an ex-slave, who fully deserved all the criticism heaped upon him and his fellows. In the pamphlet war that followed, Middleton more than held his ground, and there have been few since to question his basic division between the Greeks and the Romans over their attitudes towards medicine and physicians, or his assertion of the generally low social status of all medical men in Rome. In the subsequent two and a half centuries scholars have added little to his conclusions and few have commanded his wide range of learning. In their attempts to answer the seductive question of what the Romans thought of their physicians, prejudice has often been canonised as fact, and a traditional commonplace dignified with the title of insight.

The two classic divisions of European medical science are those of prevention and cure; and if we wish to look at the normally healthy individual in historical perspective we are speaking the language and regime of prevention. By far the larger part of individual health care is taken up by routine private maintenance, compared with which any curative intervention is an occasional public crisis. But the very nature of a multitude of low-level, dispersed acts has meant that the processes of prevention have not been as ‘visible’ to historians as the processes of cure. Investigation is further hampered by the fact that prevention has very rarely been of prime professional interest; preventive medicine was not even truly called ‘medicine’ as such. Medical historians have regarded therapeutics in general as ‘ an awkward piece of business’; and prevention in particular as a ‘murky bog of routinism’. Prevention, moreover, is and was barely newsworthy, being a passive or negative operation; in comparison, the combative techniques and reported statistics, the public and private cost of illness, are relatively accessible to the historian. Demographers and structuralist medical historians have taken disease beyond the supposedly inflated claims of curative medicine – ‘the emphasis on disease has great possibilities for it gets outside the narrow field of clinical medicine as practised by doctors’. The full range of preventive or survival techniques, however, has not so far caught the attention either of demographers or of historians.