Wednesday, 25 June 2014

Melancholy: the English Disease

The history of psychiatry and mental health – not surgery – was my first real introduction to “doing” not only early modern English history, but the history of medicine as well.  The fascination with historical understandings of mental health never quite disappeared and I hope to return to it for a post-doctoral project.

For England, the 17th century was a time of extraordinary upheaval.  Recent religious reformation and the growth of sectarian Protestantism sparked heated debates about spirituality, the senses, and emotional experience.  Political instability and ubiquitous warfare, especially the English Civil War, meant uncertainty and threats to life and lifestyle.  The Little Ice Age, frequent and devastating epidemics, coupled with an already low life expectancy meant a compromised physical state.  Increasing urbanization, crowded conditions, and widespread poverty meant a stressful existence. 

As Michael MacDonald observed, the period was marked by an increasing awareness of madness, melancholy, and suicide. 

Indeed, this is an era where great literary figures like Spenser, Shakespeare, and Milton wrote of the passions and madness and the people flocked to Bedlam to observe the mad. 

Melancholy became known as the English disease. 

But what is melancholy?  And how did early modern medical practitioners define and treat it?

Diagnoses and understandings of disease categories – then as now – are created in specific times and places. 

18thC portrait of a "typical" melancholy face.
One needs only to look at the firestorm over the DSM for illustration.  The manual’s first edition (DSM-1) was published in 1952 with newer editions published each decade to revise both disease definitions and the criteria used to diagnose specific ailments.  Controversial revisions include the removal of homosexuality as an expression of a sociopathic personality type.  Under the DSM-5, grief, happiness, worry, and even behaviours like forgetfulness or absentmindedness have become symptomatic of mental disorders. 

Revisions to diagnostic definitions and disease categories reflect both newly discovered pathophysiological explanations of psychiatric disorders and changes in social and cultural values.

For early modern Britons, melancholia was a very real and severe affliction.  Like hypochondria it “attacked the sedentary and those who had too much time to think,”[1] a fact which gave rise to the stereotype of the melancholy gentleman.  Though not exclusively an affliction of the √©lite, melancholy affected an inordinate number of the upper classes.

The Galenic humoural explanation of disease dominated early modern medical practice; mental illness, more specifically melancholy, was not exempt.  Galen’s humoural explanation for disease was based upon the theory that there were four main bodily fluids – namely black and yellow bile, phlegm, and blood – and that all illnesses stemmed from an imbalance of these humours. 

In the case of melancholy, it was assumed that it was caused by an excessive of the black bile, or the melancholic humour.

Simon Forman ((31 December 1552 -5 or 12 September 1611) 

Simon Forman was an astrological physicians who generally subscribed to a Galenic theory of illness.  Despite his leanings toward to the occult, he never made pure use of astrology to diagnose a disease, nor did he use the supernatural or preternatural to explain illnesses wherever possible. 

In fact, there were cases in which Forman rejected the notion that witchcraft was to blame for an illness, and instead favoured a physical cause.  As he stated, “Many…persuade themselfes to [be] bewitched or forspoken or possesset with spirits, and…many…thinke themselues to be this or that through much melancholy oppressing the braine and hearte.” 

Forman associated depression with melancholy, and believed that grief could also trigger the illness. 

As Forman noted during his diagnosis of Robert Burton, he found “heaviness, wind in the bowels and belly (flatulence), unlustiness (lack of sexual desire), [and] stopping of the veins (lethargy).” 

Interestingly, Forman also denoted various types of melancholy, whose nature was dependent upon with which humor black bile mixed.

John Hall (1575-25 November 1635)

John Hall, Shakespeare’s son-in-law, was a general practitioner, who treated everything from “asthma, dropsy, sterility, cancer…emphysema, worms and jaundice.” 

Select Observations was printed posthumously
Throughout his Select Observations on English Bodies there are eight diagnosed cases of melancholy: two cases recorded simply as “melancholy,” five as “melancholia hypochondriaca,” with the last cross-listed with stupidness. 

Hall, like many of the physicians under consideration, recorded cases of both melancholy and hypochondriac melancholy without distinguishing between the two illnesses, and thus gives the impression that the two terms were interchangeable, referring to the same disease.  Those that were diagnosed as simply melancholic, however, were also recorded as suffering from “fits of the mother.” 

Hall noted the many symptoms of melancholy for each patient, and it is evident that while the recorded diagnoses differed nominally, there was a clear understanding not only of what melancholy consisted, but also of how it could be contracted. 

Pains of the head, as in the cases of Captain Basset and Mrs. Wagstaff of Warwick, or spleen, as found in most recorded cases of melancholy were noted.  Although dedicated to humouralism, Hall also noted the commonly thought cause of melancholy in the case of Mr. John Trap.  Trap was a minister who had a naturally melancholy temper; this was only exacerbated by “much study [and he] fell into Hypochondriac Melancholy, and pain of the spleen.”

Thomas Willis (27 January 1621-11 November 1675):

Thomas Willis’s account of melancholy is quite similar to that of John Hall.  Like Hall, he regarded splenetic people as being melancholic:

they tended to expectorate frequently and complained of vague left-sided pains as a consequence of the defective organ.  In those predisposed to melancholia the spleen failed to ferment the ‘more early and melancholic parts of the blood’ which degenerated into ‘an acid or vitriotic diathesis’ causing melancholy as he believed that ‘there is a great sympathy and relationship between the brain and the spleen.’

Instead of hypochondriac melancholy, however, we find cases diagnosed as depression.  These cases were nevertheless clearly recognized by Willis as forms of melancholy, as he stated in both cases that they were “of melancholic temperment [sic]” and “liable to hypochondriacal states” or “hypochondriasis” respectively. 

Willis included one particularly peculiar case which demonstrates his faith in humoural theory.  The case was that of a woman named F. Bodily who was excessively melancholy.  Bodily had recently given birth and was in the process of breastfeeding her child when, as Willis stated, “the milk taken by the infant was infected with a melancholy juice or black bile,” and as a result, the child contracted melancholy from its mother.

Sir Hans Sloane (16 April 1660-11 January 1753):
Hans Sloane, like the other general practitioners of the day, treated cases of mental illness.  Of these, there was one case diagnosed as hypochondriac melancholy.  The patient, a man by the name of Barrett, is an anomaly in the study of melancholy. 

Sloane himself notes this, stating that “it is not very ordinary (though it sometimes happens) to find labouring  Men troubled with this Distemper as this Patient was, who was very diligent, and wrought land about a Pen of Cattle, and small Plantation he had some few Miles out of Town.”

Though Sloane did not explicitly state his adherence to Galenism, it is clear that humoural theory has a profound effect upon his practice as his first inclination, similar to that of his contemporaries, was to simply purge the patient.

Treating Melancholy

As these physicians generally attributed melancholy to an imbalance of the humours, they unsurprisingly prescribed similar herbal or chemical concoctions with the addition of a variety of dietary restrictions, exercises and leisurely pursuits. 

Yes, *that* Richard Burton
Herbs such as sarsafras, sarsaparilla, aloes, wormwood and calomel were designed to purge the patient; hartshorn, ammonia, saffron, garlic, soap (probably black soap), and horseradish were used to promote sweating; aromatics such as wormwood and cinnamon were used to restore elastic and tone.  

Barbara Traister notes two melancholic cases in which Forman recommended purges – one of which was the case of Richard Burton, while Sloane recorded that he also recommended purges in his only case of melancholy. 

John Hall also recommended these medicines, while adding no small number of his own.  These included mallows, beets, violets, borage, and fennel.

Other than herbs and chemicals, physicians advised patients in matters of diet and leisure in order to cure melancholy.  As Forman, in his treatment of Richard Burton, stated: “the sufferer should be surrounded with pastimes and mirth, eat fat and sweet meats, and get lots of sleep,” and that “poultry, herbs, and young white wine are to be consumed.”

Let me know what you think here or on Twitter – I’m @medhistorian.

Works Cited:

Jones, Harriet.  Shakespeare’s son-in-law, John Hall, man and physician.  Hamden,
Conn.: Archon Books, 1964.

Sloane, Hans. 1707. A voyage to the islands Madera, Barbados, Nieves, S. Christophers and Jamaica, with the natural history ... of the last of those islands; to which is prefix'd an introduction, wherein is an account of the inhabitants, air, waters, diseases, trade, &c. ... Illustrated with the figures of the things describ'd, ... In two volumes. London: printed by B. M. for the author. 

Willis, Thomas, and Kenneth Dewhurst. Willis's Oxford Casebook (1650-52). Oxford:
Sandford Publications, 1981.

Willis, Thomas, and Eugenius Philiatros. The London Practice of Physick. Boston:
Milford House, 1973. 

Traister, Barbara.  The Notorious Astrological Physician of London: works and days of
Simon Forman.  Chicago: University of Chicago Press, 2001.

Turner, E.S. Call the Doctor: A Social History of Medicinal Men.  New York: St.
            Martin’s Press Inc., 195                          

[1] E.S. Turner, Call the Doctor: A Social History of Medicinal Men (New York: St. Martin’s Press Inc., 1959), 71.

Friday, 13 June 2014

The Early Modern Kobayashi-Maru: Advertising Surgery in 17th Century England

How, precisely, does a surgical practitioner advertise?  The idea sits uncomfortably – a flashy ad, some neon lights, maybe Vince-the-ShamWow-guy?

Seventeenth century London handbills or advertisements are as fascinating as they are important.  Littered with cure-alls, promises of “no cure, no money,” and intriguing images, advertisements can also reveal which ailments required a patient to see a surgeon, and what kinds of treatments were available, and the advertising strategies used to convince a patient to see a surgical practitioner. 

Not a handbill - this is from the title page of Salvator Winter’s A Pretious Treasury (1649)
Upon reading the advertisements a pattern quickly emerges.  Venereal disease is, by far, the most frequently mentioned ailment mentioned.  Next, surgeons advertised their ability to treat ruptures, the stone, eye, ear and teeth maladies, inflammation, and cancers.  Skin ailments like harelips, leprosy or “scall’d heads” featured prominently alongside other visible outward manifestations of disease such as buboes, scabs, and “breakings-out all over the Body.”[1]  So called “oculists” who couched cataracts advertised frequently and made up a specialized group of surgical practitioners.  

Cornelius Tilburg treating a man’s eye complaint
It is impossible to judge the magnitude of disease outbreaks or the pervasiveness of certain ailments based on these advertisements.  Venereal disease was rampant throughout London and was represented as such by its frequent mention in handbills.  Skin diseases and the stone, also well represented, were the surgeons’ domain. 

Stomach ruptures or “broken bellies,” however, are likely overly represented in the advertisements.  John Schultius explained ruptures as when one’s “guts cannot be kept in.”[2]  Along with falling wombs and anal prolapses, gut ruptures represented one especially bizarre manifestation of the desire to keep everything and everyone in their proper place.  To this end, surgical practitioners offered manual operations while others offered trusses – contraptions meant to hold the gut (or anything else) in place.[3]

Anon. Ruptures cur[‘d] by Bartlett of 
Goodmans-[Fiel]ds, (1660?)
Surgical practitioners, it seemed, also had some difficulty convincing potential patients to undergo an invasive operation.  Like general health treatises discussed, many of these advertisements suggested internal remedies for surgical ailments. Both Mr. Elmy the operator and the unnamed surgeon who lived at Mr. Brett’s apothecary sold medicines to be taken inwardly.[4]  The latter, in fact, stressed that he provided “inoffensive Medicines, that a child of Twelve Months old, may receive the Benefit without the least Uneasiness.”[5] 

Gilbert Anderson, a self-proclaimed physician and former military surgeon also advertised his services.  Anderson highlighted his military service as evidence of his competence, using counterintuitively, his lack of experience with the challenging operation of amputation.  Instead, Anderson framed this lack of experience as a positive characteristic; it was evidence that he was not hasty to perform an invasive, painful, and radical operation when other easier, painless, and minor solutions were at hand.[6] 

As observed with Samuel Pepys, fears of being cut for the stone could delay the decision for years.  Some quacks preyed on those fears, emphasizing the “hazard of cutting, which often proves more fatal than the Disease,” to advertise their concoctions.[7]  For example, an unnamed German man offered a powder that cured both the stone and rickets while a man calling himself a physician offered “an infallible  Medicine” that dissolved bladder stones.[8] 

It is no surprise then that when Abraham Souburg advertised his services, he stressed that he was able to remove the stone without using an instrument (or more than one instrument), arguing that it was the use thereof that caused collateral damage to the area and made patients lame.[9]  He went further, writing that he would give “six hundred Rix Dollars,” to anyone who could produce a patient he had harmed by cutting for the stone.[10]  Even Tilburg offered inward medicines for the stone.[11]           

In comparison to those offering physick for surgical ailments, few offered solely their surgical skills for the same.  Simple surgical procedures such as bleeding or extracting teeth were likely the easiest operations to convince patients to undergo by virtue of their simplicity. 

David Perronet and Benjamin Willmote both advertised offered their services for both dental work and phlebotomy.  Cost may have also been a factor – in the latter case, Willmote charged only six pence for the service and Perronet suggested that it could cost six pence or a shilling.[12] 

The treasurer’s records of St. Thomas Hospital give some idea of cost; major operations, it seemed, had a standardized cost: for dismembering a limb, cutting for a rupture, and cutting for the stone, surgeons were paid three shillings and four pence.[13]  For dismembering a finger, William Perse received one shilling eight pence.[14] 

Venereal diseases were much more difficult and expensive to cure; one advertisement suggested ten shillings as sufficient payment for curing the pox and five shillings for gonorrhea.[15]  

John Russell’s advertisement depicting the surgical operations he was willing to perform
In contrast, when practitioners offered medicines for surgical ailments, the cost was generally lower.  James Wasse Senior advertised his Wasse’s Elixir, it was sold by the half pint for three shillings with printed directions.  The elixir promised to cure agues, gout, and convulsions and even dissolve an cure bladder and kidney stones.[16]  Mr. Elmy the operator offered a remedy for all head pains, eye diseases, and memory that shed the bad humours without surgery; for this he charged one shilling six pence for 10 pills or three shillings for 20 pills.[17]  Even Perronet, though he pulled teeth, admitted that this was an inconvenient solution and offered special ointments and elixirs for sore gums and rotted teeth that ranged in price from six pence to one shilling.[18] 

The generally lower cost coupled with the promise of a painless and easy cure was likely more appealing to patients than a regimen of cutting, excising, stitching, and dressing.  Even John Russell, whose advertisement boldly depicted patients undergoing manual operations, used the textual portion to advertise his cures by medicines, noting that he cured one woman’s breast cancer specifically “without cutting.”[19] 

In effect, popular treatises and surgical advertisements both presented the same message: surgery was a painful and dangerous option to be avoided when medicinal remedies could suffice.
Forget Kobayashi-Maru - let's talk about Pepys's dilemma.

Let me know what you think here or on Twitter - I'm @medhistorian.

[1] Anonymous. “A Secret Which Has Been Found” Wing S2351B; see also BL 551.a.32, 112.
[2] BL C112f9, 27.
[3] BL 551.a.32, 143 and Anon. Ruptures Curd by Bartlett of Goodmans Field.
[4] BL 551.a.32, 84 and 10.
[5] BL 551.a.32, 10.
[6] Gilbert Anderson, All Praise and Glory be Given to God Alone, London.
[7] BL 551.a.32, 122.
[8] BL 551.a.32, 25 and Anonymous, At the Sign of the Two Faces, London.
[9] BL 551.a.32, 140.
[10] Ibid.
[11] BL 551.a.32, 3.
[12] Benjamin Willmote, The Highly Approved English Deaf Curing Doctor, London and David Perronet, His Universal Dentifrice, London.
[13] LMA H01/ST/D/04/001.  Treasurer's Common Acquittance Books Containing signed receipts for payments made by the Treasurer, including salaries of staff. See especially Molins comment regarding the stone on 1 June, 1674 and Hollier for dismembering and the cutting of a rupture on 13 Aug, 1674 and 14 November, 1674 respectively.
[14] LMA H01/ST/D/04/001, 27 April, 1676.
[15] Anonymous, Glad Tidings To Unfortunate Venerial Patients, London.
[16] Anonymous, James Wasse Senior Citizen and Surgeon of London, London, 2-6.
[17] Elmy, At the Blew Ball, London.
[18] Perronet, His Universal Dentifrice, London.
[19] John Russell, John Russell, Professor of Physick and Oculist, London, 1-2.