Diseases of Modern Life Flashcards
Timmerman (2011), emergence of chronic disease as a category
20th C, first in USA and later elsewhere in industrialized world
Post-war:
term ‘chronic’ was increasingly used as a synonym for ‘non-communicable’
acute phases of these ‘new’ chronic diseases were thought to be preceded by long, symptom-free periods, even dormancy, and triggered by various forms of stress—not unlike consumption in the early nineteenth century.
it may have been the
shortage of adequate facilities for patients with long-term illnesses in the USA (compared with the relative abundance of pauper beds in Britain and France, for example) that prompted the emergence of chronic disease as a new, distinct category
Kleinman, distinction between ‘illness’ and ‘disease’
‘illness’ = the experience
‘disease’ = an identifiable entity
Timmerman (2011), past experiences mimicking those of ppl with chronic disease in the 20th-C
sufferers from tuberculosis or syphilis, for example, once
touched by the illness, were cursed for the rest of their lives: the illness and its symptoms, abating and recurring, good days and bad days, came to define their biographies—a feature that recent analysts have described as characteristic of the modern chronic illness
experience
Illich, origins of chronic diseases (Timmerman’s Account)
characterized
chronic disease as an effect of civilization, caused by alienating aspects of modern life that
disturbed the age-old harmony of man and nature and by the failures of recent medicine.
Timmerman (2011), consumption’s persistence, summary
While it is often assumed that tuberculosis and consumption were identical, consumption, I argue, did not disappear when tuberculosis was conquered
some of consumption’s cultural meanings transferred to other chronic illnesses in the twentieth century.
René and Jean Dobos, The White Plague
much of what was described as consumption in old
medical writings was not pulmonary tuberculosis.
Until the late nineteenth century, when a patient was seen to waste away slowly and seemingly inevitably, the diagnosis was usually consumption.
Timmerman (2011), consumption
Rather than being synonymous with tuberculosis—a diagnosis that presupposes the identification of tuberculous lesions in post-mortem examinations and,
following Robert Koch (1843–1910), the demonstrable presence of a specific bacillus— consumption was associated with the clinical picture of patients deteriorating, sometimes rapidly, sometimes over years.
Wasting diseases whose final stages were often characterized as consumption included also scurvy, scrofula, and various forms of cancer.
Conditions such as asthma or dropsy were also linked to consumption
Consumption, thus, was not a distinct disease entity, but rather, being consumptive was a personal quality
Once consumptive, incurable.
Chronic illness signalled a
weak constitution irreparably damaged by a life lived carelessly or under unfavourable conditions.
Consumption was thus the endpoint of much chronic illness
pulmonary tuberculosis remained a chronic, incurable disease until the mid-twentieth century, despite considerable investments.
Timmerman (2011), perceived causes of consumption
If an individual had a consumptive diathesis, that is, an inherited
proneness to consumption, the illness could be brought on by a variety of precipitating factors.
Overindulgence, for example, might merely lead to a salutary attack
of gout in an individual with a strong constitution, clearing the blood of purulent matter. In
individuals with a weak constitution, be this due to poor inheritance, previous illnesses, or
bad habits, the same behaviour might trigger consumption.
Timmerman (2011), importance of patient stories
they complement longue durée histories of disease that focus merely on statistical patterns. They tell us what illness meant for individuals and also
illustrate the role of individual patients in a historiography of medical progress that has
traditionally been written exclusively around contributions by medical researchers.
Sanitary Commission for Investigating the State of the Infirmaries of Workhouses for The Lancet in 1865
Multitudes of sufferers from chronic diseases, chiefly those of premature old age, crowd the so-called
‘infirm’ wards of the houses, and swell the mortality which is a melancholy characteristic of these establishments. Examples are not uncommon in which the really able-bodied form but a fourth, a sixth, or even an eighth of the total number of inmates.
Timmerman (2011), shift in process of diagnosing consumption
What defined the disease in the classificatory system promoted by Laennec
and his followers was no longer a (potentially infinite) set of symptoms that the physician considered in the context of the patient’s biography, but the existence of a finite number of specific disease markers in the body
Peitzman (Timmerman’s account)
diagnosis of Bright’s disease in a person with no symptoms, based merely on a urine examination, ‘represented an entirely new manner of transforming a person into a patient … The felt bodily sensations of the patient and the patient’s recounted story of them, would increasingly lose their primacy and power
Timmerman (2011), Diabetes mellitus
Matthew Dobson (d.1784), a Liverpool physician, suggested that the sugar was not formed in the kidneys but removed from the patients' blood, explaining their emaciation. A succession of dietary therapies followed, which attempted to feed sufferers with foods their bodies could assimilate, but with minimal benefits
Children under ten years of age could expect to live no more than three years following diagnosis, while elderly patients survived for about twice as long.
diabetes became model for the long-term management of other conditions being identified as chronic diseases. When the
British clinician Smirk experimented with the clinical use of the ganglion-blocking drug hexamethonium for the treatment of malignant
hypertension in the early 1950s, he implemented a similar regime, instructing patients to self-inject the drug with tuberculin
syringes
Isolation of peptide hormone by Banting, Best et al
1921
First British insulin available
1923
Patients’ had to have own regime of self-injection - power back to them from clinicians?
Timmermans (2011), renal failure
identity of renal failure was similarly transformed when, from the 1960s, dialysis was increasingly available to chronic renal patients. These new regimes required a high degree of organization and self-discipline.
Timmerman (2011), antibiotics and drug companies
Antibiotics since the 1940s cured many chronic infections and shortened hospital stays.
Following the antibiotic bonanza, drug companies proved keen to develop the market for cardiovascular
drugs and other treatments for chronic illness, which promised stable and long-lasting profits.
Timmerman (2011), TB and welfare
1911 National Insurance Act was partly motivated by concerns over tuberculosis. The Medical Research Council had its roots in this context: its precursor institution, the Medical Research Committee, was established to promote research into this disease. Many of the new welfare services in the interwar period were dedicated (besides mother and child provisions) to tuberculosis,
Timmerman (2011), changing mortality and morbidity patterns and their significance
Deaths in childhood/adolescence had declined rapidly
more people lived past
middle age, making illnesses associated predominantly with middle and old age, such as heart disease, strokes, or cancer, much more visible
By 1950s, mortality rates for TB lower than cancer
lung cancer sole contributor to increase in cancer deaths: work by R. Doll (1912-2005) and A. B. Hill (1897-1991)
rise of welfare administrations and the growing costs associated with this development turned the prevention of these conditions into an important issue for public health policy.
Graph of the 1962 Report by the Royal College of Physicians on Smoking and Health (Timmerman, 2011)
mortality from a number of respiratory diseases among men aged 45 to 64
around 1950, for the first time, mortality from tuberculosis in this cohort was lower than that from cancer
Also, lung cancer alone was to blame for the increase in cancer mortality, a disease that by the mid-1950s had been firmly linked to smoking cigarettes
US National Health Survey 1935-6
over 700,000 households in 83 cities
nearly 1/5 of population had a chronic disease or disability
Joint Comte on Chronic Illness formed
1945
by the American Hospital Association, the American Medical Association, the American Public Health Organization, and the
American Public Welfare Association.
Committee passed on the baton in 1949 to a Commission on Chronic Illness, which published four-volume report in 1957.
Welfare Council of New York study, 1928
20,700 people incapacitated by chronic conditions
Only one-fifth of these (403) were over 70 years old; more than half were under 45.
NY Welfare Council estab comte on Chronic Illness
1933
chaired by Boas
With its ageing population, Boas argued, America was facing a social and health crisis to which a public health system focusing on mortality alone could not do justice
Journal of Chronic Diseases launched
1955
Timmerman (2011), shift in US approach to chronic disease post-WW2
in Cold War context, shift away from social factors to clinical parameters
Heart disease and cancer were increasingly associated with affluence,
public health interventions were aimed at educating people individually to reduce their personal risks of developing health problems later in life
Post-War chronic disease in Britain (Timmerman 2011)
urvey commissioned by the Ministry of Health in 1954 focused on the provision of services, finding that the majority of chronic sick beds were in former municipal and Poor Law hospitals
much of the accommodation was unsuitable, in damp buildings with narrow staircases and without lifts, with insufficient bathrooms and dayrooms, and poor heating and lighting. All was still distinctly reminiscent of the workhouse. As in America, patients in these institutions were increasingly medicalized
However, in Britain this led to the development of geriatrics as a specialty
editorial in the Journal of the American Medical Association
we find ourselves in the fifth phase of an epidemiologic transition: the ‘age of obesity and inactivity’
Timmerman (2011), critique of Omran
Omran’s article suggesting epidemiologic transitions has contributed to the misguided notion that chronic disease has only become a problem in the twentieth century
In order to arrive at a more nuanced picture of such continuities and change,
we need more histories that contrast and challenge the statistics-driven master narrative behind the theory of epidemiologic transition
Timmerman (2011), similarities between chronic diseases of the 20th/21st C’s and those of the 19th C and earlier
chronic illness in the early twenty-first century is still linked to individual biographies and constitutions, and blamed on behaviours associated with civilization
Jones et al. (2003), PTSD, methodology
Using historical medical files of soldiers who served in the Boer War and in the First and Second World Wars, we have attempted to test the hypothesis that the symptom clustering associated with PTSD existed before psychiatrists recognised it as a formal disorder
Testing in partic, incidence of flashbacks - largely limited to PTSD as diagnostic tool
1856 cases were included (Table 1), drawn from seven conflicts and representing ten diagnoses
Previous historical investigations have relied on single case studies to make the point that PTSD is a timeless disorder
However, such studies lack a denominator and are instead based on an active search through historical literature for descriptions that resemble modern formulations of PTSD, while presumably discarding presentations that appear different.
Dean (1997), PTSD
symptoms of PTSD, including flashbacks, can be identified in the accounts of veterans of the American Civil War
Trimble (1985), PTSD
‘this relatively common human problem has been known for many hundreds of years, although under different names’
Young, PTSD
PTSD is a culture-derived diagnosis and can only have existed in the late 20th century
Mumford’s analysis of the Iliad
showed that the heart alone (and not the head or the abdominal organs) was associated with emotional distress
In the Hebrew Bible too, he found that the heart was interpreted as the seat of the emotions, will and intellect
significantly different somatic vocabulary from that of today and the one reflected by PTSD.
First Diagnostic checklist for PTSD published in DSM-III in 1980
- flashbacks - ‘Re-experiencing of the trauma’. Recurrent recollections, dreams, feeling as if trauma reocurring. 1987, DSM-III-R included ‘flashback’ as synonym for some aspects of these experiences
First Diagnostic checklist for PTSD published in DSM-III in 1980
- intrusive symptoms (such as nightmares, flashbacks and persistent memories) (1987, DSM-III-R included ‘flashback’ as synonym for some aspects of these experiences)
- avoidance symptoms (such as emotional numbing, withdrawal from the world and avoidance of reminders)
- symptoms of overarousal (such as insomnia and irritability)
Jones et al. (2003), PTSD, conclusions
Analysis of the 1856 cases revealed that flashbacks, symptoms of intrusion and avoidance, were virtually non-existent before the First World War and were still rare during the Second World War
Although not a common phenomenon today, their incidence is significantly higher than in previous conflicts
Somatic symptoms appear much more often in presentations of post-trauma illness from the 19th and early 20th centuries - somatic descriptions = poss explanation for rarity of flashbacks WW1 and 2
Shellshock, for example, was often depicted by contemporaries in terms of contractures, tics, movement disorders and paresis
psychopathology of trauma is not static and that culture has an impact on the expression of distressing memories
PTSD is one more phase in the continually evolving picture of human reaction to adversity
Reasons for rise of the flashback
- Shorter - nature of medically unexplained syndromes has itself changed, with a shift from apparently neurological symptoms such as paralyses, tremors and fits to more ill-defined and subjective symptoms such as fatigue, pain and depression
- Blank - direct association between the flashback and films/ rise of cinema
- Yet films were an integral part of popular culture during the First and Second World Wars, when flashbacks appear to have been much rarer than today. Involuntary visual images may be tied more closely to the mass production of affordable television sets in the 1950s and 1960s and the subsequent introduction of video recorders. supported by the intrusive nature of the flashback. People make a conscious choice to go to the cinema. television in the home can be a source of sudden and disturbing imagery in a familiar and apparently safe situation.
Petrie, Wessely (BMJ, 2002), mistrust of modernity
Over recent years there has been a steady and important change in the public’s perception of the relation between aspects of modern life and health. Now, at the beginning of the 21st century, people’s suspicion of modernity has increased to such an extent that it has undermined their view of their own health, increased their worries about environmental causes of poor health, and fostered a migration to complementary medicine
Petrie, Wessley (2002), medical significance of general mistrust of modernity
This anxiety is reflected in the pattern of presentations of psychosomatic illness: the number of illnesses attributed to environmental factors—for example, sick building syndrome, multiple chemical sensitivity, total allergy syndrome, and 20th century disease—has increased
Bc ppl feel more vulnerable, normal everyday symptoms such as headache and fatigue are now more easily interpreted as signs of disease or ill health.
Petrie, Wessley (2002), reason for unease with modernity
increase in the public’s fascination with personal health and medicine, as evidenced by the burgeoning of gyms and fitness programmes, and the widespread adoption of a “healthy lifestyle.
The media’s increased coverage of health topics, in stories on the dangers lurking in ordinary activities such as air travel and vaccination, has raised worries about routine health care
Well publicised crises, most obviously bovine spongiform encephalopathy and foot and mouth disease, have severely dented confidence
focus of the media on risks with a novelty value fosters the belief that they are far more common than they actually are
the internet - new and unsubstantiated health worries can be instantly transmitted to an internet audience eagerly seeking information on health or to special interest networks, such as illness support groups. A recent US study of hospital outpatients found that 25% of the patients had used the web for medical information in the past year
med scares transmitted on web + via email - antiperspirants causing breast cancer
result of this deluge of information on the supposedly pervasive risks to personal health is that people now feel much more vulnerable.
Petrie, Wessley (2002), reasons for unease with modernity
increase in the public’s fascination with personal health and medicine, as evidenced by the burgeoning of gyms and fitness programmes, and the widespread adoption of a “healthy lifestyle.
The media’s increased coverage of health topics, in stories on the dangers lurking in ordinary activities such as air travel and vaccination, has raised worries about routine health care
Well publicised crises, most obviously bovine spongiform encephalopathy and foot and mouth disease, have severely dented confidence
focus of the media on risks with a novelty value fosters the belief that they are far more common than they actually are
the internet - new and unsubstantiated health worries can be instantly transmitted to an internet audience eagerly seeking information on health or to special interest networks, such as illness support groups. A recent US study of hospital outpatients found that 25% of the patients had used the web for medical information in the past year
med scares transmitted on web + via email - antiperspirants causing breast cancer
result of this deluge of information on the supposedly pervasive risks to personal health is that people now feel much more vulnerable.
Petrie, Wessley (2002), new technologies
The rapid introduction of new technologies has been accompanied by important adverse effects in the way people make sense of illness and present with health complaints.
DSM
Diagnostic and Statistical Manual
of the American Psychiatric Association (PTSD 1st included in DSM III)
Bracken & Petty, 1998
called into question cross-cultural export of PTSD counselling programmes to non-Western communities who have suffered wartime violence
McFarlane, psychoanalysis (Bracken’s account)
McFarlane suggests that the decline of interest in psychoanalysis as an explanatory model has decreased the emphasis on unconscious conflicts in the causation of psychiatric disorders, which in turn has lead to an increasing focus upon life events, and in particular, traumatic life events, as causative factors.
Judith Herman (1992), trauma (Bracken’s account)
there has always been a tendency to push traumatic events, not only out of individual consciousness, but out of social consciousness as well.
discourse on trauma has emerged because of a number of political developments, most importantly the rise of the women’s movement in Europe and North America
The advent of feminism, she suggests, by allowing a recognition and understanding of the effects of rape and other forms of sexual violence, has made it possible for psychiatrists to examine the effects of trauma and to take the victims’ accounts of their suffering seriously.
large-scale social movements which opposed the war in Vietnam allowed for a critical examination of the effects of wartime experiences
PTSD has always existed but has remained almost invisible to psychiatry until recent polit developments
Young, trauma discourse (Bracken’s account)
origins late 19th century when the notion of the ‘traumatic memory’ became popular in medicine
recent discourse on trauma has inherited this concept but has also been substantially shaped by a number of theoretical developments in American psychiatry
the concept of PTSD has been constructed over time; it has a history
PTSD has come to be constructed on account of changes in psychiatry itself - t is part of an effort to secure a scientific basis for psychiatric classification
Bracken (2001), PTSD and culture
concern with psychological trauma is not simply a clinical issue, it would appear that it is also a cultural event
A number of clinicians and researchers have argued that the characteristic intrusive and avoidance symptoms of PTSD can be best understood as evidence of the victim’s search for a new sense of meaning and order in the world in the wake of the traumatic experience.
Cognitive theories have become dominant in this area and most researchers assume that trauma produces its effects by undermining the unconscious models or ‘schemata’ which serve to structure an individual’s reaiity
Horowitz, Stress Response Syndromes (1986)
‘information processing’ model of trauma
A traumatic event presents information which conflicts with pre-existing schemas. There is thus an incongruity which gives rise to distress. This provokes a ‘stress response’ which involves reappraisal of the event and revision of the schemas. If the event is highly traumatic this process is prolonged. However, until such time as the process is complete, the event remains stored in ‘active memory’:
Because the representation of the traumatic event is stored in active memory it is replayed over and over again, each time causing distress for the individual
To prevent emotional exhaustion, inhibition and facilitation processes become involved.
If there is a failure of inhibition, intrusive symptoms such as nightmares and flashbacks occur.
Bracken (2001), cognitivist vs anthropological approaches
cognitivists - psychology and culture are separate realms.
While culture may help shape an individual’s understanding of the world, there are universal psychological processes which make such understanding possible in the first place. It is these that are damaged by trauma
Anthropologists - Kleinman -
very basic aspects of our reality are culturally constructed.
Culture shapes emotions
Jenkins (anthropologist)
need to look at ‘collective trauma’: Because traumatic experience can also be conceptualised collectively, person-centred accounts alone are insufficient to an understanding of traumatic reactions
Summerfield, based on his work as a psychiatrist in Nicaragua
the individualistic concept of PTSD cannot grasp the cultural dimension of suffering in times of war, particularly in non-Western settings
Button (1995)
while rejecting Descartes’ ontological dualism, cognitivism continues to endorse his epistemological separation of inner mind from outside world
Bracken (2001), postmodernity and meaning
contradictions of post-modern society are simply exaggerated tensions which have always existed within modernity. One of the key features of modernity which makes it different to what Giddens refers to as ‘traditional society’, is its extreme dynamism.
In most Western societies there has been a move away from religious and other belief systems which offered individuals stable pathways through life, and meaningful frameworks with which to encounter suffering and death. During the same period the individual self, although more important than ever before, has been undermined by the very forces which assert this importance
For in the post-modern condition the self becomes the source of the meaning of the world while at the same time it becomes disconnected from that world.
Within the cultural horizon of late or postmodernity individuals live their lives without recourse to firm foundations. While this offers unprecedented freedom for individuals to define their own identities, their relationships and their beliefs about the world, it also brings with it a burden of what Giddens calls ‘ontological insecurity’.
Bracken (2001), PTSD and postmodernity
If attempts to reestablish a sense of coherence and order are what lie behind the intrusive and avoidance phenomena codified in the syndrome of PTSD, and these efforts are, to some extent at least, driven by the structures of the surrounding culture, then, we would expect that in cultures which cannot be characterised as modern or post-modern there might well be very different reactions to terrible events
PTSD thus the product not of trauma in itself but of trauma and culture acting together
PTSD is the product of a particular cultural situation. It is a disorder of our times
Giddens, three elements of dynamism of modernity
- separation of time and space
- social and cultural institutions become separate from local contexts and stripped of specific local orientations
- reflexivity
Caplan (1995), Railway spine timeline
- Born in 1866 as exclusively somatic disease
- 1880s - confusing psychical ailment
- 1890s - a state of somatic-psychic flux
- Early death in 1st decade of 20th C
- Contribd to fundamental restructuring of the somatic paradigm and re-legit of psychogenic notions of causality
Name of the condition - railway spine - was indicative of late 19th C med’s materialistic orientation
Caplan (1995), how did railway spine present
Railroad accident, then cases of full or partial paralysis, headaches and various aches and pains oft emerged at later date
wide variety of symptoms:
eg. defective memory ill temper hot head perverted taste and smell sexual impotence
cld only be diagnosed from patient’s symptoms
John Eric Erichsen, Railway spine
1st to describe group of symptoms, mainly nervous, that frequently occurred after a concussion of the spine
Argued by way of analogy and according to clinical observation
Similarity w Beard - sought to apply single label to wide variety of symptoms
Caplan (1995), railway spine and gender
men more likely to be victims since most likely to travel by rail
Presence of apparently hysterical symptoms in men convinced Erichsen that symptoms elicited by railway accidents and other traumas must be indicative of some serious organic disturbance
- Inconceivable that man cld display hysterical symptoms w/o serious organic disturbance
Smith-Rosenberg, sympathy
hysterics typically denied the sympathy granted to sufferers from unquestionably organic ailments
Herbert Page, building on Hodge’s analysis (opponents of Erichsen)
Symptoms emerging at later date cld only be explained by psychical factors
Fright itself = capable of eliciting neuromimetic symptoms by way of some willful hypnotic state
Disappearance of symptoms following financial settlements
Patient shld be freed from hurtful sympathy of friends
This = one of the first exclusively psychological explanations for both cause and cure of functional ailments
Medico-legal controversy
Prior to publication of E’s lectures, accident victim who failed to display clearly discernible anatomical or physiological symptoms not likely to fare well in a court of law
E’s book forever altered this situation
Plaintiff - used Erichsen - organic - injury to spine
Defence - Page - simulation
Role played by juries was source of special irritation to railway surgeons and the corporations they repd - tendency to sympathise w plaintiff
At trial, plaintiffs likely to win almost 70% of cases against railroads, and such findings rarely overturned on appeal
Financial impact of Erichsen’s work
In 1st decade following publication of his book, English railway companies paid more than $11 million in damages
Similar figures cited for the US
Hundreds came from those seeking compensation for spinal concussion, or what an eminent physician soon termed ‘Erichsen’s Disease.’
R D Wallace
Railway spine = merely a symptom of the present ‘epidemic of madness and insane furor against the railroads and othe rcorporate enterprises.’
Response to Growing incidence of alleged cases of spinal concussion and the frequent willingness of juries to find for the plaintiffs
formation of several regional assocs of railway surgeons
First such local assoc was estabd Jan 1882
Over course of the decade more than 50 additional local organizations established
28 June 1888 more than two hundred mems - representing several of these organizations - met in Chicago and founded the National Assoc of Railway Surgeons
Later that yr, the assoc issued the first volume of the Natioanl Assoc of Railway Surgeons Journal
Denied reality of spinal concussion
Outten, chief surgeon for Missouri Pacific Railway
sympathetic attention of friends and loved ones aggravates patient’s condition by fixing his mind on his ailments and suffering
Physicians’ role in creating this condition - when crashes in cities more railway spine cases bc more physicians to say so - 20x more accidents (neurologists partic to blame)
Outten and other American railway surgeons had inadvertently generated a novel synthesis regarding hypothesis and suggestion
Traumatic neuroses, while legit med ailments, were typically the afflictions of the hereditarily tainted and morally suspect
Borrowing from Charcot
Claims railway accidents merely triggered preexisting tendencies.
Their oft dismal plight bore little or no relationship to train wreck - like dry powder in search of a match
Where free of vices, Bernheim’s psychical doctrines more enticing - used to shift blame from accident to attending physician and sympathetic friends, loved ones, lawyers
Punton - failure of enforcement of isolation to be sufficient ground to excuse any railroad company from further responsibility of any claims
American railway surgeons thus unwittingly became first American med specialty to achieve consensus regarding therapeutic value of what wld soon be known as psychotherapy
Caplan (1995), therapeutic signif of railway spine debates?
little
Prior to first decade of 20thC, nervous disorders, regardless of perceived etiology and pathology, were treated in virtually identical manners
Porter (1993), diseases and social groups
Practically all humans live in social groups
All diseases at least trivially = diseases of civilization
Infections e.g. measles need pools of susceptibles to provide continuous chains of hosts in space and time
Fact of history at least until recent times that disease incidence runs in direct ratio to settlement density
Porter (1993), disease and urbanity
17th C rise of ‘new diseases’ - e.g. rickets, assoc by contemps w deleterious facets of urban life
TB widely ident as essentially an urban diseases, esp tragic bc cuts off young in prime
Rural enclaves oft escaped epidemics
19th-C, correlation between disease and the city appeared most inescapable
1852 ‘Great Stink’ from Thames forced adjournment of Parliament
Spread of big city life apparently making pops more vulnerable to new modes of ailment midwived by modernity e.g. hysteria, hypochondria
20th C, great killer infections that had so long decimated urban communities were in rapid retreat
Affluent city came to be recognized as site of the most effective h-c delivery system
It is the First World - urbanized, industrialized, civilized, that enjoys longevity and salubrity at close of 20th-C
Porter (1993), early modern med
Link between societies and sickness made explicit in Early modern med
Charting, containing and curbing town-specific diseases exercised med administrators of early modern Europe
Public-hlth experts in Renaissance Italy promoted and perfected quarantine protocols
Riley, Enlightenment
renewed methods made during Enlightenment to document disease and plot patterns of incidence against natural and social-environmental factors such as climate, waste disposal etc
Porter (1993), rival aetiological thoeries
‘Contagionists’ - indiscriminate bodily contacts towns created
‘Miasmatists’ - e.g. Chadwick, argued the new ‘shock towns’ produced highest concentrations of garbage, rotting refuse, decaying animal, faeces etc, all of which emitted gaseous effluvia, which were disease in own right or at least its bearers
Others emphd moral links - idleness, indigence, ignorance amongst w-c’s bred lifestyles which bred disease. Greeat pop of such arguments on both sides of Atlantic during cholera pandemics 1830s and 1840s
Porter (1993), diseases of civilization as ideological construct - early use
Concept of ‘diseases of civ’, superimposing medical and moral, 1st activated 18th C - serving as secularized revamping of Christian legend of the Fall, wherein Original Sin and expulsion from Paradise had inaugurated the regime of hard labour, disease, suffering and death in the temporal world
Rousseau - ‘primitivist’ - and popularizing physicians e.g. Scot George Cheyne - argued what might be termed ‘noble savages’ and their sturdy hunter-gatherer and peasant descendants, of necessity pursued hlthy life-styles
Devel of town life led to deleterious habits e.g. (590) over-eating, hard drinking
Artificial demands of smart, high-pressure high society and enlightened living amongst literati and glitterati were seen as creating new world of diseases
Porter (1993), diseases of civilization and central nervous system
Cheyne, Tissot and followers -
discarding conventional theories of humoral balance, they emphd that key to hlth and happiness lay in correct nervous tone
Excessive consumption of fine foods and alcohol, and lack of exercise, combined to obstruct the nervous fibres
Notion of diseases of civilization went hand-in-hand w increased explanatory import of the central nervous system
1670s, Thomas Sydenham guessed that about 1/3 of all disorders in Br were ‘nervous’
By 1800, Trotter was suggesting their incidence had doubled
‘nervousness’ cld be taken as symptom of success no less than sickness
Applied to nations as well as individs
Porter (1993), notion of ‘diseases of civ’ in 19th C
19th-c that notion of ‘diseases of civ’ attained greatest credibility and max scare-power
Shift - instead of diseases of civilization and signifying superiority, idea’s dark side became dominant
Partly bc certain disorders that fell under epithet’s umbrella grew more deadly, above all TB, which climaxed around mid-19th C, accounting for up to 1/4 of all urban deaths in north-western Europe and eastern US seaboard, esp those of young adults
Leading TB docs e.g. Beddoes explicitly blamed the menacing curse of the disease upon the effete and aetiolated hot-house life-styles cultivated by the beau monde
Porter (1993), cultural anxieties maturing after 1850
- Growing stress on role of heredity in spreading sickness down generations
- Social Darwinist view that nations and races locked in struggle for survival that would penalize weakness
- W rise of class tensions and social strains in age of industrialization, widespread feeling the social body itself was sick
- fears grew that soc itself being crippled by growing burden of delinquent and maladapted - parasites of the ghetto and its subcultures - degenerationism
Porter (1993), degenerationism
- Originally assoc w Morel
- Socio-cultural traits of modernity were morbidly self-destructive
- US nerve-doc George Beard, career strains in the business rat-race devitalized high-flyers - Cerebral circuits suffered overload
- Widely assumed that the degenerate would breed disproportionately
Lombroso = pioneer of….
anthropometry and psychiatric criminology which employed cranial measurement and photography to identify the diseased sectors of civilization, w view to isolating, treating or even sterilizing criminal and prostitute types, atavists and immoralists
Porter (1993), eugenicism
- direct response to perceived rise of degenerate underclasses
- Immigration restrictions - Aliens Act 1905
- US - several state legislatures promoted programmes of castration and sterilization
- Nazi programme of race hygiene
Freud (Porter 1993)
- complaints commonly presented by patients e.g. depression cld be attribd to psycho-pathology of everyday life in modern, urban, affluent civilization
- Bourgeois respectability and prudishness and delayed marriage took heavy psychological toll
- ‘repression model’ presumed that biologically healthy drives e.g. libido were necessarily suppressed to meet demands of social order
- Resulted in pschological and psychosomatic disorders
Rise of social medicine (Porter 1993)
- 1930s and 40s
- championed in partic by Winternitz at Yale and Ryle at Oxford
- devel of sci med under bacteriology was counterproductively narrow
-Epidemiology had to move
beyond the pathology laboratory and into society as a whole
- Sickness trends = functions of social variables such as class, income, status, occupation
—> what was psycho-socially triggered could not
adequately be treated by pharmaceutical or surgical interventions alone.
- Bc of their research and publicity efforts, became common wisdom that certain sorts of disorders consequential upon deleterious life-styles and environments
Porter (1993), rise in ‘new’ conditions 20th C - optical illusion?
e.g. caused by more precise diagnostic techniques
more intense screening
Porter (1993), qualifications to attempts to dress up old myth of ‘diseases of civilization’ in new garb
- Black Report and other British surveys: heart attacks pre-eminently afflict not social groups one and two but four and five - the poor, deprived, under-educated
- Much in heart disease that has been assoc w category of ‘civilization’ may be attributable specifically to nicotine
- W spread of hlth ed, enlightened eating habits, seems likely that today’s so-called diseases of civilization are not in any straightforward sense the products of affluence, but rather diseases disproportionately afflicting the least privileged mems of advanced socs
- cancers, heart conditions, respiratory diseases etc are rapidly worsening amongst the masses of the Third World, evidently spread by industrial toxins, dietary dislocation, cigarette smotking
- AIDS - for many moralists, the quintessential disease of modern life-styles - has mainly devastated Third World
Porter (1993) - ideological indictment of modern life-styles oft extended to modern med
- Suggested such diseases as cancers have defied sci research and resisted cure precisely bc methods of sci (fixated upon reductionistic, materialist approach to the body, and expectation of specific remedies, a ‘pill for every ill’) are inappropriate for handling systemic and constitutional disorders, from MS to ME, whose aetiology may include an irreducible psycho-somatic component and be personality linked
- Illich: modern med = one of the prime diseases of civilization, not only spreading iatrogenic disorders, but orchestrating a disabling ‘expropriation of health’.
Porter (1993), allure of alternative medicine
lies in its ability to link philosophies of sickness to a wider disaffection w, and critique of, industrial soc, nostalgically evoking myths of golden ages of hlth and seeking a return to Nature
Porter (1993), irony of civilization-blaming
still exercises a powerful Romantic hold, largely over those who are the greatest beneficiaries of the civilizing process itself
Wessley (1990) thesis
the origins of ‘ME’ lie not in 1955 or 1934, but in the last century, and in the condition known as neurasthenia
