Illness
Illness
Illness, deviance, and social control
In non-Western, relatively nonindustrialized and nonurbanized societies, illness is characteristically perceived, defined, experienced, and treated as a condition that is not only biological, psychosomatic, and metaphysical, but also “sociosomatic” in nature. That is, illness is viewed as a physical, spiritual, and psychological state that is significantly influenced and can even be caused by such social and cultural factors as the social status an individual occupies and the reactions it evokes in him and in others; the quality of his relations with the members of his family and with other persons important to him or to his kin; and the strength of his commitment and the degree of his conformity to the norms and taboos of his society.
Although this insight is also a part of Western medical thought and tradition, for many centuries in Western societies it was overshadowed by a preoccupation with the “natural,” physical causes of disease, their detection, and their mastery through the media of science and technology. It was not until the mid-nineteenth century in European and American societies that an appreciation of the role of social and cultural factors in health and illness became salient and organized enough to lead to the contention that “medicine is a social science” and to the expression of that conviction in a series of public health, social hygiene, and social medicine measures and movements (Rosen 1963). In the mid-twentieth century the attempt to understand the interrelationships between physical and emotional illness, on the one hand, and social and cultural forces, on the other hand, has become sufficiently analytic and systematic for the emergence of a scientific subfield that might appropriately be called the “sociology of illness.” This empirical area of inquiry is not a domain exclusive to sociology. Rather, it has developed out of the convergent and collaborative investigations of internists, psychiatrists, psychologists, and cultural anthropologists, as well as sociologists. In this regard, it reflects a trend larger than itself—a progressive tendency for interdisciplinary work in the behavioral sciences.
Illness as a social role. Perhaps the most important theoretical contribution to the sociology of illness has been made by Talcott Parsons in his conception of illness as a social role characterized by certain patterned exemptions, rights, and obligations that are shaped by the society of which the sick person is a member (T. Parsons 1948; 1951; 1958; 1964; T. Parsons & Fox 1952). Parsons has defined the attributes of the sick role in contemporary Western society, and particularly in present-day American society, in the following way. First, the sick person is exonerated from certain kinds of responsibility for his illness: he is not held morally accountable for having gotten sick, nor is he expected to make himself better. He is also considered to have some impairment in his capacity to carry out normal role and task obligations, and thus, according to the nature and degree of his illness, the sick person is exempted from some of his usual activities and responsibilities. Moreover, because of these rights and exemptions, which are not normally accorded to persons in the society, the sick person may be said to be cast in a type of deviant role. This is a deviant role that is partially and conditionally legitimated—one that is contingent on certain obligations to which the sick person is subject. Thus the sick person is expected to define the state of being ill as undesirable and to do everything possible to try to get well. Above all, he is enjoined to seek technically competent advice and help, preferably from a qualified physician. In so doing, he enters the role of patient, who is expected to facilitate his recovery by cooperating with a doctor. In modern Western society this includes willingness to submit to the techniques and facilities of medical science, to the ministrations of other designated medical personnel, and to hospitaliza-tion if it is deemed necessary.
Definitions of illness. Once designated as ill by socially authorized medical agents, the individual gains access to certain rights and becomes subject to certain duties. What he presents as a potential illness to a medical practitioner, and what the practitioner in turn diagnoses, certifies, and treats as illness, is determined as much by social and cultural factors as by biological considerations. The extent to which the definition of illness and treatment is contingent on the state of society’s knowledge, its prevalent value system, and its institutional structure was insightfully satirized by Samuel Butler in his novel Erewhon, written in 1872. In Erewhon (the fictitious country that Butler created by imagining late nineteenth- and early twentieth-century England stood on its head), persons afflicted with what physicians would call tuberculosis are found guilty in a court of law and sentenced to life imprisonment, whereas persons who forge checks, set houses on fire, steal, and commit acts of violence are diagnosed as “suffering from a severe fit of immorality” and are cared for at public expense in hospitals. Indeed, it is a historical fact that over the past few centuries in western European and American societies, partly as a consequence of certain far-reaching social and cultural changes, we have seen a progressive process by which persons with psychological disorders, who in an earlier era would have been adjudged “wicked,” “possessed by the devil,” or “criminal,” have come to be regarded as mentally or emotionally ill and treated accordingly [seeSocial Control].
This close and sensitive interrelationship between social and cultural forces, on the one hand, and the attitudes, sentiments, and behaviors defined as illness in a society or group at a given time, on the other hand, has been amply documented in medical and social scientific literature. Numerous studies demonstrate that what constitutes an illness or disability in one society or in a particular subgroup of a society is not necessarily regarded as such in other societies or groups. For example, the Navajo Indians of the southwestern United States do not view a congenital dislocation of the hip as a disease or handicap (McDermott et al. 1960, pp. 280-281). In “Regionville,” a town in upper New York State, members of the highest socioeconomic class generally report a persistent backache to a physician as a medical symptom, whereas members of the lowest socioeconomic class regard it as an inevitable and innocuous part of life and thus as inappropriate for referral to a doctor (Koos 1954).
The anthropological and social psychiatric literature also contains descriptions of patterned beliefs and behaviors that would be considered manifestations of emotional illness in modern Western societies, but which in traditional tribal or folk milieus are part of the culturally accepted and sanctioned magicoreligious system. In rural villages of the western region of Nigeria, for instance, elére or elegebe are alternative terms applied to a child who is believed to have invisible little people three feet high as playmates. The parents of such a child respond in the culturally indicated way by providing small feasts for these miniature beings in order to invoke their benevolence and protection (Cornell-Aro …1963, pp. 36, 80, 146-147). Finally, anthropological field workers have reported certain symptoms, apparently sociopsychosomatic in nature, that seem to be unique to a particular society or subculture—for example, coléra, a culturally patterned attack of rage that occurs among the populations of Indian villages in Guatemala (Paul 1953), and empacho, a stress-induced digestive condition that affects Mexican-Americans in Texas (Rubel 1960).
The experience of illness. In modern Western society, an individual who is defined as ill and cast in the sick role is regarded as being in a state attributable to causes that fall outside the realm of both his personal control and his moral responsibility. However, it would seem, as Bronislaw Mali-nowski has eloquently suggested (1925), that illness is an emotional and an existential experience of such magnitude for human beings that they generally find it difficult to think of their illness in purely nonmetaphysical and nonmoral terms, even when the society of which they are members encourages them to do so. There is a paradoxical sense in which a society or a group that insists upon an exclusively logico-rational explanation of sickness, thus precluding religious, moral, or magical considerations, may augment rather than decrease the “problems of meaning” with which persons in that society feel themselves confronted when they become ill. At any rate, such empirical studies as we have of the deeper emotional reactions of gravely ill, hospitalized patients in present-day American society reveal them as grappling with the “whys” of their illness in moral, religious, and cosmic, as well as medical terms; they do not have the easily available, legitimate recourse to the transcendent explanations provided by most non-Western, less science-oriented societies (Fox 1959, pp. 132-135).
The experience of illness as an event that is more than natural may be universal. But the particularities and nuances of the emotional meaning of an illness to an individual and the nature of his affective response to his state and symptoms are profoundly influenced by his social and cultural background as well as by his personality traits. For example, it has been observed that people in Japan like to go to bed with mild illnesses not only because they receive attention for small aches and pains but also because illness provides the patient and family members who care for him with a culturally approved way of living out and nonverbally communicating the sorts of deep, tender feelings of love and concern that are not ordinarily expressed in even the most intimate of relations between Japanese (Caudill 1961).
Whereas the emotional atmosphere around illness in Japan tends to be “peaceful,” intensive case studies of southern Italian women hospitalized for schizophrenia reveal that a striking number of these patients feel and act in a “jealous, capricious” pattern that is apparently related to some of the competitive, aggressive, emotionally charged, and labile ways of reacting and behaving that are characteristic of socialization and family life in southern Italy (A. Parsons 1960). Emotionality and volatile behavior in the face of both physical and psychological illness have been observed to be characteristic not only of patients of southern Italian background but also of Jewish patients. This is in part a consequence of the fact that the expression of strong feelings is socioculturally permitted, expected, and favored in the Jewish and Italian families from which these patients come; in these particular groups, crying out in the face of illness is felt to be a way of helping to get the sickness “out of one’s system,” along with the emotions it engenders, as well as a way of mobilizing the intensive concern and support of one’s family (Mechanic 1963; Zborowski 1952).
The degree to which this highly affective way of responding to illness is contingent on social and cultural factors is supported by the finding that patients from other social groups with socialization and family patterns that discourage the exhibition of certain kinds of strong feelings show a consistent tendency to behave in a quite different characteristic fashion. For example, patients of Anglo-Saxon Protestant origins who are afflicted with pain-accompanied conditions have been noted to be controlled, forbearing, and almost clinically detached in their attitudes and behaviors (Zborowski 1952), whereas seriously ill Irish-American patients have been reported as engaging in counterphobic, gallows humor and joking behavior as one of their shared ways of coping with the physical and emotional stresses of their situation (Fox 1959, pp. 175-177, 190).
Not only do the basic emotional meanings of illness and patterned ways of reacting to it vary systematically in certain ways from one group to another, but also in illness, as in health, society and culture penetrate so deeply into the unconscious layers of the individual’s psyche that they even influence the inner imagery he experiences. This is most clearly seen in connection with emotional illness, where social and cultural factors are among the most important determinants of the extent to which patients have delusions and fantasies, how rich and elaborate they are, and precisely what form they take (Cornell-Aro …1963; Opler 1959; A. Parsons 1961; Paul 1953).
Illness, deviance, and social control
In virtually all societies the person who is ill is regarded as being in an exceptional and implicitly deviant role. Manifestly, as in modern Western society, illness may be defined as “not the fault” either of the person beset by it or of those with whom he is interrelated. In certain historical eras and in particular religious and moral contexts, illness may even be looked upon as an indicator of a special state of grace. For example, in traditional Christian thought disease is regarded as a form of suffering that purifies the soul of man and brings him closer to God (Sigerist 1960), and throughout most of the nineteenth century in western European society there was a romantic tendency to associate tuberculosis with intellectual and artistic genius (Dubos & Dubos 1952, pp. 44-66). But inherent in even such sympathetic and glorifying cultural attitudes toward illness is the conception that sickness is a state that is not, and ideally should not be, the collective and continuing fate of many persons; that is, it is a condition out of which one should graduate if possible, through a combination of will, effort, good fortune, and the help of others.
If one begins to reflect on what would be the consequences for a society if a large proportion of its population were to secede from normal social tasks and obligations, invoking illness as their legitimate reason for doing so, it becomes apparent why illness is usually socially defined as a kind of deviance and why, in every society, the right to certify illness as bona fide is assigned only to certain persons in certain roles. The effect of great numbers of persons in a society taking to their beds could, in its passive way, be as disruptive of the usual functioning of that social system as an insurgent refusal on the part of those same individuals to tend to their daily activities and responsibilities. The exemption, withdrawal, and dependence that illness characteristically entails is an especially strategic and threatening form of deviance in certain kinds of societies—for example, in the United States, with its high cultural emphasis on responsibility, activity, achievement, and independence (T. Parsons & Fox 1952), or in Soviet Russia, where, in the name of the collective industrial and agricultural development of the society, maximum effort, work, and productivity are expected of all citizens at all times (Field 1957, pp. 146-180).
In modern Western societies, the agent who screens signs and symptoms, makes a professional judgment as to whether or not they constitute illness as the society he represents defines it, and formally certifies an ill person as legitimately meriting certain dispensations is the physician. In so doing, he performs several latent social control functions. He sorts out “malingerers”—those who unconsciously or consciously feign or simulate illness—from those who are authentically ill, according to the medical and scientific criteria recognized and institutionalized in the society (Szasz 1956). In principle, he refuses to acknowledge the conditions of malingerers as real and legitimate illnesses and denies them the exonerations of sickness. With respect to those individuals whom the physician certifies as ill, he sets into motion a therapeutic process, which is composed of sociopsychological as well as physical elements and which is designed to return the patient to full-scale participation in his society. In modern Western society the focal site of this process has become the hospital.
The functions of hospitalization
The prevalence of hospitalization is associated with the specialized personnel and facilities that scientific medicine can now bring to bear on the diagnosis and treatment of illness. In the hospital trained professionals, technical apparatus, and medicaments are coordinated and mobilized in a way that could scarcely be replicated in a physician’s private office or in a sick person’s home. Reinforcing these manifest technological and administrative reasons for the widespread hospitalization of the ill in modern Western society are latent sociopsychological factors.
As Parsons and Fox have pointed out (1952), the small, conjugal, relatively isolated, close-knit, emotionally intense family unit characteristic of such an urbanized and industrialized society, with its focus on the formation and integration of the personalities of its members and its emphasis upon achievement, is prone to certain difficulties in dealing with illness. The sick role, comprising as it does a semilegitimate channel of withdrawal from adult responsibilities and a basis of eligibility for care by others, is inviting to various family members in patterned, often unconsciously motivated ways. To the wife-mother of the modern urban family it offers an institutionalized way of reacting to her heavy affective-expressive responsibilities in the family and a compulsively feministic way of reacting to her exclusion from certain prerogatives and opportunities open to the man. For the husband-father, illness legitimizes respite from the discipline, effort, and dualistic demands of interdependence and autonomy that his occupation demands of him. For the child, being moved by the process of socialization along the tension-ridden path toward adulthood, illness provides an escape from increasingly exacting obligations to behave as a mature person. And for the elderly individual, retired from the occupational system, widowed, and with no traditionally assured place in the families established by his children, illness may serve as an opportunity to solicit forcibly their concern and care.
Not only are the members of the modern urban family prone to illness in these sociopsychologically influenced ways, but they are also likely to be emotionally threatened by the illness of a person in their small, tightly knit, affectively toned family unit with its particular kinds of strains. Under these circumstances there is a high probability that the family will overreact to the illness of one of its members with either excessive sympathy or excessive severity. Such responses can impede the full and rapid recovery of the ill person.
In the light of these family vulnerabilities, it would seem that one of the important latent functions of hospitalizing the sick person is to insure the more effective social control of illness. Hospitalization places the patient in an extrafamilial setting, where he is less likely to be emotionally reinforced in illness and where professional objectivity and dispassion in the attitudes and behavior of the medical staff provide leverage to move him out of the sick role. At the same time, isolating the sick person from members of his family mitigates their emotional strain and thus helps them resist the contagious temptation to take to their beds in response to the situation.
The hospital as a social system
However, life in the ward of a hospital is accompanied by its own particular stresses and potential seductions. A small but steadily growing number of studies of (largely American) psychiatric and general hospitals as social systems has yielded some insights into what it is like, sociologically and psychologically, to be a hospitalized patient (Belknap 1956; Caudill 1958; Coser 1962; Davis 1964; Fox 1959; Goffman 1961; Greenblatt et al. 1957; Stanton & Schwartz 1954). The physical and psychological symptoms of illness and the attributes of the sick role that the individual enters once he is diagnosed as ill subject him to certain tensions, regardless of whether or not he is hospitalized. These include incapacity and inactivity; uncertainty as to the prognosis and eventual outcome of the illness; in some cases, the objective prospect of nonrecovery and the imminence of death; problems of meaning; isolation from the world of the normal and healthy; submission to the authority of medical science, the physician, and other medically trained personnel (Merton … Barber 1963, pp. 111-113). Entering the hospital as a patient, however, increases the extent to which the ill person is removed, psychically and socially as well as physically, from the universe of the healthy. It subjects him totally to the care, control, and technology of modern medicine and the complex team that administers it. Under certain conditions it makes him a potential object of medical experimentation and research (Fox 1959). And it introduces him into a new “small society,” which demands that he become an adjusted and cooperative member. [SeeDeath.]
Every one of the studies made of the hospital as a social system describes it as an elaborately structured, rigidly stratified, tightly disciplined bureaucratic organization. These characteristics are viewed as functionally related to the fact that the hospital staff must survey and regulate virtually all the activities of a large number of patients and to the fact that the staff must be geared to respond to medical exigencies, dangers, and emergencies with the synchrony of a precise, resolute, swift-moving team. These characteristics of the hospital have at least two significant consequences for the attitudes and conduct of patients.
Patients who are hospitalized for a long time may become so habituated to a predictable round of daily activities and a clearly delineated set of duties, rights, and privileges that any alteration in them may be experienced as disturbing. In the case of children, this routinized compliance to an impersonal institutional authority may have dysfunctional consequences for their psychosocial development. It may cause them to regress, at least temporarily, to an earlier stage of socialization where they depend more on external than on internal superego type controls (Davis 1964, pp. 120-123).
Another effect that the social organizational properties of the hospital can have on patients is best demonstrated by Stanton and Schwartz’s microanalysis of the social and psychological dynamics of pathological excitement and collective disturbances of patients in the wards of a mental hospital (Stanton & Schwartz 1954, pp. 342-365, 378-400). In every case that they examined, they found that a high level of continuing, covert tension and conflict between staff members in charge of patients was the major etiological factor involved. What this illustrates is how intricately entwined are the relations between staff and patients in a hospital. Structurally and functionally, the interdependence within and between each group is so close-webbed that even latent tension in one part of the social system may significantly affect its other parts. The impact of such tension on patients is augmented by the magnitude of physical and psychological dependence on hospital staff that being ill entails and by the heightened perception of the attitudes and feelings of staff members that this degree of dependency may foster.
It would seem, then, that although the hospital may help insulate patients from the sorts of emotional reactions on the part of family members that might complicate or impede their recovery, it may generate structural strains of its own that can have similar nontherapeutic or antitherapeutic consequences. A basic social science insight related to this phenomenon lies at the heart of a method of therapy and rehabilitation that has come into vogue in psychiatric hospitals since the 1950s. The insight is that, even outside the formally defined treatment situation, the affective quality and content of interaction between hospital staff and patients have a significant effect on the progress of the patient. The method is what has come to be known as the “therapeutic community” approach—a planned attempt to create a hospital milieu in which the therapeutic potentialities in all relationships within the hospital are maximized and utilized for the benefit of the patient (Jones 1952; Rapoport et al. 1961).
Studies on the hospital as a social system indicate that the patterned ways in which patients adjust to illness and hospitalization are influenced as much by fellow patients as by members of the medical staff. Patients grouped together for any time in the hospital wards constitute close-knit communities, with shared ideas and norms about how one ought to think, feel, and act in the face of the common predicament of illness and hospitalization; moreover, they develop their own systems of socialization, social support, and social control for effectively transmitting and enforcing these conceptions. Despite the considerable variation in the types and composition of the wards studied (male, female, and children’s wards; general medical, surgical, and psychiatric wards; wards devoted to a particular disease; research wards, etc.), in every case the patients exhibit certain ways of coping with illness in the hospital. These include organization of the patient subculture in the form of a club with a name, charter of purposes, list of rules, and roster of offices; the cultivation by patients of medical expertise, particularly in connection with their own disorders; and the expression of potentially threatening basic emotions in coun-terphobic humor. There is evidence that the sources of such mechanisms do not lie only in the personality characteristics of individual patients or the experience of illness per se. They are also influenced by the social system properties of a hospital, by more general characteristics of the larger society into which the hospital fits, and, above and beyond these, by transsituational, cross-cultural, and perhaps even universal tendencies in the ways that human beings deal with major life stresses.
The optimally “good” and “successful” patient, by sociological definition, is the one who progresses steadily toward recovery, leaves the world of the hospital behind him, psychically and physically, and returns to full participation in his normal societal roles. In crucial ways, compliance with the norms of the sick role and those of the hospital as a social system contributes to this process. The paradox that many of the studies in the sociology of illness point up is that it is also true that the better a person becomes adjusted to the sick role, and the better his integration to the small society of the hospital is, the harder it is for him to make the sociopsychological journey back to health.
Illness confronts the sick person with psychological challenges, and it also brings him the kinds of gratifications that Freud termed “secondary gains.” It removes him from the universe of the healthy and enmeshes him in that of the hospitalized sick. By virtue of these experiences, illness may significantly alter his attitudes, values, beliefs, and behavior. This being the case, his recovery from sickness and re-entry into the world of the healthy may involve him, the members of his family, his friends, and the professional associates to whom he returns in still another process of adjustment and resocialization.
RenÉe C. fox
[See alsoHealth; Medical Care, article onethno-medicine; Mentaldisorders, treatment of, article Onthe therapeutic community; Mentalhealth; Public health.]
BIBLIOGRAPHY
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Caudill, William 1958 The Psychiatric Hospital as a Small Society. Cambridge, Mass.: Harvard Univ. Press.
Caudill, William 1961 Patterns of Emotions in Modern Japan. Unpublished manuscript.
Cornell-Aro Mental Health Research Project in the Western Region, Nigeria 1963 Psychiatric Disorder Among the Yoruba: A Report, by Alexander H. Leighton, T. Adeoye Lambo et al. Ithaca, N.Y.: Cornell Univ. Press.
Coser, Rose L. 1962 Life in the Ward. East Lansing: Michigan State Univ. Press.
Davis, Fred 1964 Passage Through Crisis: Polio Victims and Their Families. Indianapolis: Bobbs-Merrill.
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Fox, RenÉe C. 1959 Experiment Perilous: Physicians and Patients Facing the Unknown. Glencoe, III.: Free Press.
Goffman, Erving (1961) 1962 Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Chicago: Aldine.
Greenblatt, Milton et al. (editors) 1957 The Patient and the Mental Hospital: Contributions of Research in the Science of Social Behavior. Glencoe, III.: Free Press.
Henderson, Lawrence J. 1935 Physician and Patient as a Social System. New England Journal of Medicine 212:819-823. → A now classic, pioneering essay in the field of the sociology of medicine, which was the direct inspiration for Talcott Parsons’ conception of the sick role.
Jones, Maxwell (1952) 1953 The Therapeutic Community: A New Treatment Method in Psychiatry. New York: Basic Books. → First published as Social Psychiatry.
Koos, Earl L. 1954 The Health of Regionville: What the People Thought and Did About It. New York: Columbia Univ. Press.
McDermott, Walsh et al. 1960 Introducing Modern Medicine in a Navajo Community. Parts 1-2. Science 131:197-205, 280-287.
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Opler, Marvin K. 1959 Cultural Differences in Mental Disorders: An Italian and Irish Contrast in the Schizophrenias—U.S.A. Pages 425-442 in Marvin K. Opler (editor), Culture and Mental Health: Cross-cultural Studies. New York: Macmillan.
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Parsons, Anne 1961 A Schizophrenic Episode in a Neapolitan Slum. Psychiatry 24:109-121.
Parsons, Talcott (1948) 1953 Illness and the Role of the Physician. Pages 609-617 in Clyde Kluckhohn and Henry A. Murray (editors), Personality in Nature, Society, and Culture. 2d ed., rev. New York: Knopf.
Parsons, Talcott 1951 The Social System. Glencoe, III.: Free Press. → See especially pages 428-479 on “Social Structure and Dynamic Process.”
Parsons, Talcott 1958 Definitions of Health and Illness in the Light of American Values and Social Structure. Pages 165-187 in E. Gartly Jaco (editor), Patients, Physicians and Illness: Sourcebook in Behavioral Science and Medicine. Glencoe, III.: Free Press.
Parsons, Talcott 1964 Social Structure and Personality. New York: Free Press. → See especially pages 325-358 on “Some Theoretical Considerations Bearing on the Field of Medical Sociology.”
Parsons, Talcott; and Fox, renÉe C. (1952) 1958 Illness, Therapy, and the Modern Urban American Family. Pages 234-245 in E. Gartly Jaco (editor), Patients, Physicians and Illness: Sourcebook in Behavioral Science and Medicine. Glencoe, III.: Free Press. → First published in Volume 8 of the Journal of Social Issues.
Paul, Benjamin D. 1953 Mental Disorder and Self-regulating Processes in Culture: A Guatemalan Illustration. Pages 51-68 in Milbank Memorial Fund, Interrelations Between the Social Environment andPsychiatric Disorders. Proceedings, No. 29. New York: The Fund.
Rapoport, Robert N. et al. 1961 Community as Doctor: New Perspectives on a Therapeutic Community. Springfield, 111.: Thomas.
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Rcbel, Arthur J. 1960 Concepts of Disease in Mexican-American Culture. American Anthropologist New Series 62: 795-814.
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Stanton, Alfred H.; and schwartz, M. S. 1954 The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment. New York: Basic Books.
Szasz, Thomas S. 1956 Malingering: “Diagnosis” or Social Condemnation? Analysis of the Meaning of “Diagnosis” in the Light of the Interrelations of Social Structure, Value Judgment and the Physician’s Role. AM A Archives of Neurology and Psychiatry 76:432-443.
Zborowski, Mark 1952 Cultural Components in Responses to Pain. Journal of Social Issues 8:16-30.
illness
Attitudes to illness
In the developed world it is indeed science that holds principal authority over the patient's contested body, with respect to deciding about whether or not a person is ‘really’ ill, what sort of treatment is required, and who will pay for it. But other authorities are at work as well, including government bureaucrats, insurance companies, politicians, the media, history, the law, and even the patient, whose subjective judgements about his or her state of health hold greater or lesser sway according to any number of circumstances.Other societies have respected, or even worshipped, other authorities, which have in turn shaped concepts of illness. Shamanistic cultures even today conceive of illness in ways that seem to us supernatural or magical. If a person has been cursed or has committed some transgression, the true nature of the problem is discovered and an appropriate remedy sought. Supernatural diseases require supernatural cures, which often involve consultation with a dead relative, who intervenes with the gods or with powers of Nature to restore health. All this is conducted quite publicly, often under the guidance of an experienced healer, who may supply a suitable story as to why an illness has occurred. The satisfactory nature of this system is attested to by its enduring popularity, even when scientific medicine is offered as an alternative. Illness in shamanistic societies can affect individuals, but also afflicts families or even entire villages. The cure in such cases often involves isolation of an offending individual from the group, at least until the situation returns to normal.
Ancient Greek physicians were among the first to distinguish themselves from what are usually called temple healers, that is, healers relying on resort to the gods. They did so not by offering better cures for illnesses, at least not by modern scientific lights, but by appealing to the fashion for rational philosophy among the upper classes of society. Hippocratic physicians debated with their rivals in the marketplace in the same way that philosophers did, and their writings are among the earliest testimonies to the Greek understanding of nature.
The Hippocratic corpus of texts, most of which date from between 430 and 330 bce, were the work of many different authors. In a particularly significant text, On the Sacred Disease, the writer dismissed the notion that epilepsy was caused by the gods or by supernatural influence. Every disease was in some sense divine, the writer argued, because nature itself was divine. But the proximate cause of the sacred disease and indeed of every disease was entirely natural and therefore by implication subject to natural remedies. Epilepsy was caused by a congestion of phlegm that stopped up the brain and made the sufferer fall down and lose consciousness. One could easily see this by examining the brains of goats, which were particularly subject to the condition and had very phlegmy brains. This is scientific nonsense, of course, but it is also totally rational, within its own terms of reference, and was based partly on observation.
Illness, for the Greek physician, was a lack of balance and harmony with nature. The physician was therefore a student not only of the individual body, or microcosm, but of its place in the larger natural world, or macrocosm. This sort of thinking is particularly apparent in another Hippocratic work, Airs, Waters, Places. In that treatise, the writer outlined how environmental factors dictated the sorts of illnesses people suffered from and how the physician, often an itinerant, had to study the environment of the ill person before treatment could be effective. The treatise is also intensely political. The traditional enemies of the Greek city states were characterized as flabby, lazy, and decadent, as a consequence of the hot eastern environment they inhabited, and were subject to diseases of sloth as a result.
Acceptance of science
It can be argued that, after the rebirth of science in the seventeenth century, the concept (and conquest) of illness marched forward quickly. Thomas Sydenham (1624–89), the English Hippocrates, revived rational observation and dismissed excessive theorizing about disease. John Snow (1813–58) demonstrated the water-borne nature of cholera with his study of the Broad Street pump. Louis Pasteur (1822–95) and Robert Koch (1843–1910) pioneered bacteriology, and science's triumph over disease seemed nearly complete. But in fact objections to rational or scientific concepts of illness have been strenuous throughout history. These attacks are characteristically levelled against medical ‘experts’ and are largely based on cultural conflict and the vast area of human experience that science-based medical practice appears to neglect.The Roman gentleman Pliny the Elder, who died in the eruption of Mt. Vesuvius in ad 79, wrote one of the earliest and most influential attacks on rational Greek medicine in his encyclopaedia of natural history. For him, Greek physicians were not only foreigners, but murderers, preening sodomites and, worst of all perhaps, experts, who separated medicine from the general knowledge that a paterfamilias like Pliny believed was necessary to care for his estate, including its health. Greek physicians more than anyone were responsible, Pliny concluded, for ruining the morals of Rome. For aristocrats like Pliny, medicine need not be complicated. A proper regimen of health was really all that was necessary. Traditional folk remedies and rituals, like cabbage stew or inhaling the breath of farm animals, usually did the trick. These things could be learned from friends and relatives, or from reading the right kinds of books oneself.
Pliny's fulminations against medical experts enjoyed a wide audience especially among medieval and Renaissance humanists, who lauded not only the great encyclopedist's learning but also his advocacy of rural retirement and domestic economy as the road to good health and the way to avoid illness. The humanist poet Petrarch (1304–74) wrote a famous invective against learned physicians, directed at Pope Clement VI, advising him to dismiss his doctors, who did nothing but belch lies with their medicine-smeared tongues and waste people's time. Geoffrey Chaucer (?1340–1400), an open admirer of Italian humanism, echoed similar sentiments in his Nun's Priest's Tale, one of the Canterbury Tales. In this epic, the old widow who ruled the farm survived happily on very little money and needed only a temperate diet, exercise, and a glad heart to keep her healthy. Like a true Stoic, she expected to experience illness, old age, and death, but by careful living and above all by self-sufficiency she managed to be happy nonetheless without resort to physicians and medicines. Her chickens, vain to the last, believed otherwise and suffered for it.
Another sort of dissent came from religious and medical reformers like Paracelsus (1493–1541) and Van Helmont (1579–1644), who, like medical humanists, elevated folk practice, nationalism, and use of the vernacular in their medical ideas. Paracelsians and Helmontians objected to humoural explanations of illnesses. These explanations were based on the Greek idea that disease affected the entire body and was thus ‘systemic’ and individualized. Humoural illnesses required gradual treatment under expert guidance that could take weeks or even longer. The dissident Paracelsus and his followers argued otherwise. Often employing militaristic metaphors, Paracelsus argued for what would later be called the ‘ontological’ theory of disease — that is, the theory that diseases were caused by agents that attacked the body from outside and affected it only locally. Disease entities thus had a real existence outside the sufferer and affected similar people in similar ways. The purpose of therapeutics, then, was to apply counteragents, usually chemical ones, which would act quickly against the attacker.
Van Helmont elaborated on Paracelsus's hypotheses, as did others, and it is tempting to assume that the two men somehow prefigured the germ theory and modern medical chemistry. But Paracelsian and Helmontian world views undermined traditional medical authority much more radically than is immediately apparent. Like Pliny and like some Christian humanists, these medical philosophers argued that bodily ills were caused by occult and mystical influences. For them, the Greek idea of the natural cause of disease could explain very little. Paracelsus went further, to argue that ontological disease agents were poisons of sorts that were unleashed astrologically by chemical disturbances in the heavens. Exactly how this was accomplished remains unclear. But arguments like these crop up from time to time against totally materialistic explanations of the origin of bodily ills. A medical system that excludes from consideration notions of the mystical, occult, spiritual, or religious will never be entirely satisfying to many. To the understandable sufferer's question ‘Why me? Why now?’ the scientific physician might offer a statistical observation or simply deny that such concerns have anything to do with medicine. A medical astrologer could answer the sufferer very easily, as long as the patient believed in the validity of the explanation.
Faye Getz
Bibliography
Bynum, W. F. (1993). Nosology. In Companion encyclopedia of the history of medicine, (ed. W. F. Bynum and R. Porter Routledge). London and New York.
Levi-Strauss, C. (1963). The sorcerer and his magic. In Structural anthropology. Basic Books, New York.
Lloyd, G. E. R. (ed.) (1978). Hippocratic Writings. Penguin Books, New York.
See also health; shamans.
illness
ill·ness / ˈilnis/ • n. a disease or period of sickness affecting the body or mind: he died after a long illness | I've never missed a day's work through illness.