Patients, Practitioners and Lodgers: Male Sexual Health Patients’ and their Healers’ Use of Location in Early Modern Medical Encounters
2018; Wiley; Volume: 31; Issue: 1 Linguagem: Inglês
10.1111/1468-0424.12371
ISSN1468-0424
Autores Tópico(s)Medicine and Dermatology Studies History
ResumoThe 1658 edition of sixteenth-century Zurich surgeon Felix Wurtz's treatise The Surgeons Guid [sic] complained that, ‘Patients are like Children, still desiring such things which are offensive and hurtfull’.1 Early modern medical literature produced by physicians and surgeons is littered with complaints about the behaviour of their male sexual health patients. They were particularly aggrieved that reckless consumption of food and alcohol, and engaging in sexual activity undermined their efforts to cure the body. As Wurtz noted, without close supervision patients made their surgeons ‘accessary to the evill that should ensue’.2 He therefore cautioned surgeons to monitor and regulate their patients because if ‘he should not do well, then all the fault would be laid upon the Surgeon’.3 These complaints and the actions of such patients reveal that the relationship between male medical practitioners and their male patients was sometimes difficult and characterised by the tense negotiation of authority. The patients examined here all suffered from either sexual health or genitourinary conditions such as venereal disease, kidney and bladder stones, and hernias. These men were not unique, and tend to reflect the behaviour of patients more generally. Both genders were liable to manipulate healers in order to receive treatment that accorded with their own ideas about suitable remedies and therapies.4 In the complex and competitive medical marketplace patients willingly and wilfully abandoned medical practitioners who did not comply with preconceived notions of treatment. Additionally, patients who remained with one practitioner could be evasive, demanding or obstinate. They could actively or passively hinder treatment regimens. Women as well as men were obstructive patients.5 One apothecary complained that a female venereal disease patient was irregular in her behaviour and would not be confined to her chamber, her prescription, or the requisite diet to allow him to cure her.6 Medical men described how they had to change their treatment plans because women were uneasy.7 And some practitioners were overruled by the strength of their female patient's convictions, bolstered (as men were) by disparities in social and economic status.8 Scholars have explored in detail the ways in which female patients interacted with early modern healers, focusing on how ideas of modesty and the potential for eroticism shaped these encounters.9 Despite excellent studies by Robert Weston and Alison Montgomery, far less attention has been paid recently to men's interactions.10 Men suffering from genitourinary conditions often experienced shame and embarrassment and as such were, perhaps, more likely to end up in a fractious or contentious relationship with their healers.11 They also faced moments of crisis if their ailments caused impotence, infertility, and a loss of facial hair that undermined the manliness of their bodies.12 Their actions were then likely to be implicitly shaped by notions of manliness, as women's were by ideas of femininity, even as these conflicts manifested as negotiations of authority. In scrutinising men's fractious relationships, the article will prompt social historians of medicine to reconsider the relationship between men and their healers. To fully understand medical interactions in this era both male and female patients need to be considered. One tool that patients and practitioners (here referring predominantly to physicians, surgeons, and apothecaries rather than itinerant practitioners, empirics, cunning-folk and other unregulated healers) used, although not always consciously, was space – in terms of particular sites. Space could be used by both groups in their attempts to exert authority and control over the patient/practitioner interaction. Male patients used space, and place (here meaning geographical location), as part of a strategy of resistance against the investigations, diagnoses and treatments recommended by medical practitioners. Medical practitioners in turn obliged patients to occupy certain spaces to enforce their treatment regimens and utilised space to negotiate the hierarchical relationship with other practitioners. Male patients did not solely rely on space to disrupt the work of their medical practitioners, and this article does not argue that if space and place were removed from the examples below that tense interactions and struggles for authority would not have taken place. Rather it suggests that space facilitated men's articulations of their desire for particular medical outcomes or exchanges. Space is therefore one element of the patient/practitioner interaction that deserves further scrutiny. As men acted in a range of ways that disrupted the medical interaction, the article begins by exploring the various complaints, like Wurtz's, that medical practitioners made about their patients. It will then consider the role of space in these contentious relationships. The texts discussed here were published between 1658 and 1757. Printed materials discussing medicine and the body flourished from the mid-sixteenth century.13 Costly folios down to cheap palm-sized books were available in a way that they had not been before. Particularly during the civil wars when print censorship was suspended and there was a backlash against medical elitism, the availability of medical self-help literature increased rapidly.14 Between 1649 and 1699, 282 books on medical-chemical and astrological themes alone were registered with the Stationers’ Company.15 Many of these books were translations of works originally written on the continent. These European texts connected medical practitioners and interested readers, and reveal a shared medical culture. Although specific cases might not be directly comparable to customs or experiences in England, the publishers of these works believed English audiences would find them relevant. Even though large and heavily illustrated tomes were very costly, some medical texts were relatively widely read.16 Mary Fissell has shown that numerous medical texts were sold at auctions for lower prices and so circulated more widely, than brand-new copies did.17 Purchasing a work through the second-hand trade made them available to a wider cross-section of society.18 It also ensured that medical treatises had a long shelf-life, which helped to create a medical culture where changes of orthodoxy were slow to occur. Although Wurtz's treatise was an English edition of a sixteenth-century work, these texts largely cover practitioners working in the seventeenth and eighteenth centuries, until approximately 1740. These examples, therefore, consider the experience of medical care up until the time humoral theory began to be superseded by nervous medicine, and the time when medical consultations were increasingly shaped by the language of sensibility.19 The focus on the second half of the seventeenth century and the early eighteenth century is dictated by the fact that texts produced prior to this include few detailed descriptions of cases. These became a more prominent feature of surgical texts from 1660 to 1700.20 It is also dictated by the survival of manuscript case notes which are more common for this later period. It is not the intention of this article to explore in detail whether men's actions changed over this period; however, the relative similarities in many of these cases suggest that men's actions broadly were a consistent feature of medical interactions. In the earlier part of the period considered here, certain patriarchal ideals rested on notions of self-control.21 Good manners were bound to self-control of the body.22 Neglecting one's health through unregulated consumption suggested that neglect of social duties was probably not far behind.23 Being a good patient could demonstrate self-control and self-mastery, and, therefore, patriarchal manliness. Not all men attained such mastery. Wurtz and the authors of several medical and surgical treatises published, re-published and re-printed in the seventeenth and early eighteenth centuries explained that male patients were liable to be obstinate and unruly, unwilling to seek medical advice and unwilling to follow prescriptions. The continued discussion of these behaviours suggests that self-control, predominantly displayed through obedience to the prescriptions of a medical practitioner, remained an important feature of the manliness such texts perpetuated.24 Acting in an unreasonable and obstinate manner may not always have been the result of a lack of self-control, even if it was interpreted and described as such by medical authors, it may have been a deliberate strategy for asserting dominance over, or reclaiming authority over the body from, the medical practitioner. Exploring the context of French medical letters Robert Weston has demonstrated that tensions existed between elite male patients and the physicians and surgeons with whom they consulted.25 Medics were usually of a lower status than their patients and were denied the authority granted to practitioners of the law and the church.26 Practitioners’ authority was, consequently, sometimes weak and patients challenged them based on their own social status, wealth and medical knowledge.27 British healers were in a similarly precarious position. Physicians in Britain were tainted by the feminine associations of bodily care that their work connoted.28 Likewise the suggestion that they engaged in manual labour and a craft compounded surgeons’ inferiority. To combat these associations surgeons emphasised their learned traditions, technical skills and the manly aspects of their work such as the ‘fortitude to cut unflinchingly into flesh and physical strength to set bones’.29 Sexual health patients might well have posed a unique set of challenges because both the practitioner and patient feared that their manliness and authority was precarious. In the examples examined in this article the men range from ‘young’ men through to those in their fifties. Many were described as gentlemen, but others were designated with occupations, for example a senator and a surgeon. It has not been possible to consider in more depth the role that life cycle played in these encounters but that the men varied in age and status suggests that these methods of resistance and negotiation were accessible to all men, rather than specific groups. Pain and the inability to adequately complete daily activities often prompted men suffering from genitourinary and reproductive illnesses to seek medical advice and submit their bodies to the authority of a medical practitioner. However, this did not guarantee that men would not impose their own will onto a physician or surgeon, or act in rebellious ways. We should, however, be cautious of accepting accounts of unruly patients provided in printed medical and surgical texts. Lisa Smith has shown that eighteenth-century French surgeons used criticism of their patients to build ‘textual authority’ and a ‘moral advantage’.30 Wurtz fretted that surgeons would be blamed for a patient's continued ill health or death, and treatises reveal that medical and surgical writers used such stories to reinforce their own reputations of efficacy.31 In the case of failure practitioners suggested that the patient's unruly behaviour was actually to blame for continued or worsened symptoms, or death, thereby avoiding the implication that their own practice was ineffective. As suggested previously, the behaviours that practitioners complained about in their patients mirrored behaviours that were already thought to make a healthy man un-manly; an inability to regulate one's desires leading to gluttony, excessive drinking, and licentious behaviour.32 Moderate alcohol consumption was beneficial to the healing body, however, excess was considered damaging. Lisa Smith has shown that one eighteenth-century French physician believed that ‘persons subject to wine do not call the doctor except in extremity, because they know well that wine will be the first thing that they are forbidden to use’.33 Barthélemy Saviard commented in his ‘Remarks’ on a case of suppression of the urine that he was surprised that the frequency with which the condition returned could not convince the patient to live a more moderate life. He concluded ‘But he is not the first, that the most excruciating Pains could not prevail upon to quit the Passion of Drunkenness’.34 While Saviard appeared resigned to such interference, other practitioners were more frustrated by patients’ indulgences. In the observations recorded in the notebook of the Lockyer family, dating from 1675 to 1691, the medical practitioner who wrote the cases out explained that one of his patients – a man suffering from rheumatism in 1685 – relapsed because he drank too much ale, which made him ‘very angry’.35 The author told his patient ‘if he used such imoderate [sic] drinking it was in vaine’ for him to endeavour to cure him.36 … if a Patient be unruly, not caring for the Surgeons instruction, but fall on gourmandizing and drunkning, then no good is to be looked for; because the Patient refusing all natural helps, like a Swine trampling on Pearls, cannot expect any cure.42 Neither Sharp or Wurtz suggested that patients acted purposefully to counteract their medical practitioners, but they did reveal that patients rode roughshod over the prescriptions they received, implying that medical practitioners struggled to impose their authority on some patients. Inappropriate sexual activity was perhaps even more contentious for men suffering from genitourinary and reproductive disorders as poor regulation of their sexual activity may have contributed to their disorder in the first place. Wurtz was clear to point out this particular danger: ‘let wounded parties not practice Venereous lusts, whereby the worst accidents are caused’.43 Despite such cautions, some men were unable to bridle their lusts, sometimes with severe consequences. German surgeon Matthias Gottfried Purmann (whose observations were translated and published in English in 1706) recorded a case from 1694 of a twenty-eight-year-old draper treated for a watery swelling in his penis. He suffered a relapse after having sex with his wife before his condition was completely cured.44 Although Purmann did not criticise the patient for satisfying his libido, he made it clear that engaging in sexual activity was inappropriate and caused the patient's relapse, and eventual death.45 It is plausible that men returned to sexual activity as a way of asserting their belief that they had recovered. Hannah Newton has described how returning to a ‘lusty’ state was a feature of recovery narratives at this time.46 Richard Wiseman suggested in several of his observations that patients’ bad behaviour was inherently connected to their belief that they were recovered.47 If this were the case then this disruptive patient behaviour was potentially a means of reclaiming possession and authority over the body. A desire to return to daily life, and importantly to work, likely also prompted men to interpret their changing condition as a return to health.48 No matter the motivation medical writers, like Wurtz, found these behaviours frustrating and feared that bad outcomes might affect their reputation: ‘the Surgeon looseth his credit and reputation, and all his pains he bestowed will be in vain’.49 The disruptive behaviours of male patients may have been a strategy for reasserting dominance and authority, either consciously or unconsciously enacted. As will now be illustrated space provided a tool – like the consumption of food or engaging in sexual activity – for men to claim authority over and shape medical consultations and treatment. Tapping into the ways in which, as sociologist Fran Tonkiss has shown, spaces could be the objects of struggle, patients, physicians, surgeons and apothecaries determined the location of medical practice in order to claim authority over, and claimed locations as their own to dictate the medical interaction.50 Beat Kümin and Cornelie Usborne have suggested that historians need to grasp ‘Spatiality as simultaneously … a social product (or outcome) and a shaping force (or medium) in social life’.51 Katrina Navickas has emphasised that historians taking the spatial turn have tended to rely on the definitions of space proposed by Edward Soja and Henri Lefebvre – in which there is a tripartite division of space into the material and concrete, the symbolic and representative, and the lived as a combination of the two – and emphasise the representative element because it fits neatly with pre-existing ideas in the cultural turn.52 James Epstein has considered how space interacts with the performance of political authority and how the articulation of particular ideas might be shaped by and reinterpreted in spaces designated as either public or private.53 Geographers have turned to notions of ‘embodied geographies’ to consider how space might interact with the performance of power and authority, and the ways in which bodies and spaces exist in a constitutive relationship.54 The examples investigated below reveal similar notions that spaces, at certain moments, might allow patients or practitioners to articulate their own ideas about medical practice and treatment, and so achieve authority.55 Place and space were inherently linked to health and wellbeing in the early modern era.56 It was widely believed that environment, as one of the six non-naturals (rest, diet, mental wellbeing, exercise, environment and evacuations) should be regulated to maintain a healthy body. For many British writers, the best environment was Britain itself. It provided the healthiest climate, although certain fenland and marshy areas were thought to pose a threat to the body because stagnant standing water bred disease.57 Likewise, the filth of towns and cities made them unhealthy.58 This could affect those who travelled to urban areas. The death of the, supposedly, exceptionally long-lived Thomas Parr was attributed to his relocation from the countryside to London.59 Practitioners and patients put this knowledge to practical use. They created, where possible, homes and spaces that took full advantage of healthy environments and used green spaces to combat disease.60 Place – in terms of geographical location – could also be important for those living at a distance from a large town or city, who might have travelled to receive medical care from a physician or surgeon. Given the dangers that dirty city environments posed to the body, men and possibly also women, carefully considered this journey before undertaking such a trip. However, Ian Mortimer has cautioned scholars to be wary of the idea that people had to travel to urban centres for medical aid and has highlighted that most people in the rural hinterlands could access a medical practitioner quite readily; although people might still have travelled to large cities or spa towns to access a range of medical practitioners.61 As suggested here, certain places were also intimately connected with curative powers. Healing wells had a long tradition of being sites of medical pilgrimage, while spa towns, including Bath, Tunbridge Wells, Epsom and Scarborough were popular and fashionable healing locations throughout the period.62 Several medical writers throughout the early modern era produced treatises detailing the cures performed in these particular places, attributing the recovery of health primarily to the spa waters, but also on occasion making passing reference to the place itself. In his book An Historical Account of the Wonderful Cures wrought by Scarbrough-Spaw (1680) William Simpson implicitly suggested that the Spa in Scarborough was a local centre of healing – as opposed to Bath and others to which people travelled to receive a cure.63 In Mr Pala's case, who was suffering from the Jaundice, Simpson made it clear that the disease had been triggered by moving from Yorkshire to the south of the country, and that returning to ‘his own country’ in order to drink the waters was a crucial step in finding a cure.64 Medical interactions, consultations, and treatments happened in a range of locations, both physical and literary. Many interactions between male patients and their healers occurred at a distance by correspondence, evidenced by the numerous letters sent to Sir Hans Sloane housed in the British Library. Aristocratic, rural gentry and urban bourgeois patients were all treated without the practitioner ever seeing the patient.65 Despite never existing in the same space these relationships still displayed tension. Surviving letters from these encounters reveal that men experienced a moment of masculine crisis in which they spoke frankly about their bodies and revealed their medical conditions.66 Importantly, as already noted, Weston has shown that in these literary encounters physicians’ social authority was weak; this meant that imposing their ideas of treatments on patients was problematic.67 Surgeons occupied a range of medical spaces while working. Lisa Silverman has outlined that French surgical consultations occurred in patients’ homes and in a surgeon's office.68 John Douglas wrote to Sir Hans Sloane in 1722 explaining that he would ‘Cutt that Gentleman for the Stone, to morrow morning, therefore desire you will be at my House, against the Golden Falcon in Tetter Lane, exactly at half an hour after Nine’.69 This was a substantial operation and accordingly was being conducted in the operator's home. However, operations generally took place in ‘a mutually agreeable location’, with minor procedures like phlebotomy being conducted at the patient's residence.70 Surgeons also operated out of rented rooms and hospitals.71 When patients were given a say in where their procedures happened this invested them with some authority over the treatment regimen, which could be exploited if they so wished. Hospitals were becoming a more established feature of medical practice throughout the early modern period.72 The hospital was another site of negotiation and the performance of gender because they imposed patriarchal standards; not only did they require patients to submit their bodily authority to others, but they sought to regulate religious, moral and behavioural values in their patients.73 More than this, hospitals served as a means of isolating socially unacceptable groups, the plagued, the insane and the leprous.74 They were thus institutions of social control. Hospitals are not mentioned very often in the examples cited below, but it is worth noting that this setting, again, provided a locus for the negotiation of authority. Hospitals did not represent a location of medical treatment entirely separate to that of the home. In part this was because domestic townhouses housed hospitals, until the institution outgrew its settings and had to move to purpose built premises.75 Given their domestic setting it is plausible that they functioned in ways similar to what Amanda Flather has argued for middle-class domestic spaces; that they could ‘express and enforce social differences between individuals and groups by the different ways that space is used and the manner in which it is controlled’.76 Medical practitioners often worked in their patients’ homes and lodgings. In histories of medicine the home has been viewed predominantly as the site of domestic medicine, sometimes termed ‘Kitchen physick’.77 There, women like Elizabeth Freke produced complex remedies, including distillations, and used their skills to aid members of their family and local community.78 However, recent scholarship has moved beyond the gendering of domestic spaces and domestic medicine as solely feminine.79 Homes were multifaceted spaces. Businesses, especially small businesses, were run from locations that blended home, workshop and business premises.80 Tawny Paul, investigating insults in early modern Edinburgh, has identified that during working-hours, homes that also served as shops were perceived as semi-public, if not entirely public spaces.81 Outside of working hours men claimed domestic spaces as their own, a sanctuary of power and authority.82 Men claimed authority by occupying particular spaces and their movement through spaces required bodily techniques and appropriate displays of their position.83 The ability to restrict access to parts of the home also connoted authority. Certain parts of the home were not open even to those who lived in the household.84 Masters, for example, might bestow access to certain rooms in the house upon apprentices as a favour, or restrict their access to enforce their own authority over the house.85 There is little evidence that patients restricted the access of their medical practitioners, although it may have been that competition between different types of healers was expressed through the willingness of some groups to visit patients more freely or by providing a more open and accessible space themselves.86 Given their need for succour this is perhaps not surprising. However, the medical consultation was a peculiar mix of the intensely personal and commercial activity and patients may well have interpreted the penetration by a non-family member (although medical practitioners could of course be family members) into the home as a relinquishing of authority. Domestic sites of medical treatment were, and are, inherently dynamic, shifting depending upon the actions of the social actors inhabiting them. The ability to claim certain spaces was at certain times a feature of authority, including during medical consultations and treatments. Practitioners visited men's domestic spaces when needed but were not on hand permanently to monitor treatment and recovery. Occasionally they may have stayed with a patient: John Wyndham who was suffering from disrupted sleep caused by ‘gravel’ (small kidney or bladder stones) noted that his doctor came to him on 11 April 1747 and departed on the 29th of the same month.87 In dire or apparently dangerous situations, doctors sometimes also remained near the patient.88 The physical separation of practitioners from their patients appears to have undermined their authority in directing medical care. The select cases of John Woodward, a physician working in late-seventeenth- and early-eighteenth-century England, were published in the mid-eighteenth century. The editor, Dr Peter Templeman, noted that ‘It may be thought, perhaps, that he is sometimes tedious in his Narration’.89 This tedious detail, while annoying to Templeman, reveals how this arrangement of visiting patients facilitated men's unruly and obstinate behaviours. Describing Mr Whitehead, a wine merchant who ‘appear[ed] to be betwixt Fifty and Sixty’ and suffered from nephritic pains and suppression of the urine, Woodward explained that he had ordered a lenitive and unctuous electuary. Mr Whitehead initially took the medicine as ordered but seeing that it worked and ‘being averse to all Medicines, he left it off’ allowing his symptoms to return.90 Mr Whitehead, following the behaviours outlined previously, disrupted and resisted his medical care based on his own assessment of his health. Woodward's absence from the space of medical treatment facilitated this, as he was not present to enforce Mr Whitehead's compliance. In a note from 2 August 1719 he recorded that ‘visiting him this Morning, I was sorry to find he had not taken the oily Draught. He finding himself now pretty easy, being unaccustomed to Medicines, and having an Aversion to them’.91 That Woodward only visited the patient sporadically, and that treatment presumably occurred in the patient's own home or lodgings, perhaps bolstered his belief that following his own authority in such matters was preferable. As with other observations Woodward used this commentary as a means of explaining why the patient relapsed and had to take further prescriptions: ‘I was sent for to him this Morning and found him in great Distress’.92 Woodward, like other practitioners, used stories like this to build a rhetoric designed to shame patients into appropriate behaviour. However, we can also see here that by including descriptions about the location of medical care Woodward was implicitly attempting to claim authority over patients’ homes when they were used for medical treatment. It was important, he suggested, that patients remembered that even when they were in their own homes they should submit to his authority in order to secure health and well-being. A patient's chamber (bedchamber) was often cited as the location of medical treatment and healing. The chamber had associations in the early modern period with women's health as the final stage of childbirth and parturition occurred in the lying-in chamber; a space created by keeping the chamber dark and warm. Women confined themselves to this space both before and after birth.93 A letter from Ralph Radcliffe to John Radcliffe from 1738 emphasises though that the chamber was important for men as well as women. Reporting of a friend Ralph commented that ‘Mr W[illia]m Hale is confined to his chamber by a fall he had leaping in his park. But I hear he will soon be able to come down stairs’.94 Similarly Samuel Pepys recorded in his diary for 23 October 1662 that Sir William Penn, a naval officer, was confined to ‘bed’ by gout; Penn received Pepys in his chamber on several occasions because of his condition.95 Penn's chamber functioned as a permeable and adaptable space where medical men, family members, friends and colleagues came and went. This was likely not an unusual concept as traditionally, although not at some points in the era, the monarch received his courtiers and advisors in his chamber. Moreover, having a separate bedchamber was not a ubiquitous feature of early modern life. For many people their parlo
Referência(s)