Tutorial Essay, M.Sc. Medical Anthropology
Michaelmas Term, 3rd Week
Paper 1: Introduction to Medical Anthropology
Essay 2 on illness narratives, case histories and case records
Barbara Gerke
Why is Barbara Duden’s study on The women beneath the Skin relevant to medical
anthropologists?
The eye of culture sees in the order of nature what it expects to see.
Barbara Duden 1991:113
Introduction
Barbara Duden’s The women beneath the Skin presents a rare early 18th century account of
documented case records on “Weiberkrankheiten” (women’s diseases) by Dr. Johannes
Pelargius Storch, the town physicus of Eisenach, now in eastern Germany. The body
perceptions of the doctor and his clientele reveal a metamorphosis within the body at a time
where physiology and anatomy had not yet been assimilated as medical concepts into the
consciousness of most people.
Medical anthropologists raise questions regarding different illness concepts and the influence
of religion, ritual, economy, linguistic and socio-political environments on the perceptions of
body, health, disease, illness and sickness, arguing that their experience and knowledge are
mediated by the culture they develop in. The discipline has found a valuable place among
medical, historical, social and anthropological sciences to engage intensively in the study of
culture-bound illness perceptions.
This essay discusses four areas in Duden’s study and their relevance to medical
anthropologists:
1.
2. Historical changes in perceiving medical epistemologies,
3. Research approaches,
4. The cultural environment influencing Storch’s medical practice and perception, and
5. Body perceptions of Storch and his women patients.
All of these areas reflect the multi-dimensional factors involved in 18th century body and
illness concepts.
1. Historical changes in perceiving medical epistemologies
Previously, Storch’s records were considered irrelevant for the history of medicine, because
he did not physically examine his patients and could not make any contributions to the history
of gynaecology. It needed a woman and historian like Barbara Duden to unveil the body
experiences and concepts of 18th century women beneath the written lines of a physician who
was trained in the newly developing biomedical concepts, but still gave so much attention to
the women’s voices. Storch was a physician at the threshold of an era where public body
perceptions still dominated the anatomical and biological body concepts, which were
developing under the increasing influence of rational thought and science.
Storch, “stood in the centre of a living, if vanishing tradition” (p.117). He is an ambassador of
the transitory process, because, first he was trained in anatomy and physiology by followers
of the “mechanical doctrine”; second, he was not medically determined and the patients in no
way shaped by definitions (p.23). Up to the time of Storch, the body as experience was
dominant. Storch's struggle was to force his own body concept into the scheme of Stahl’s
anatomical categories. Although his own body concept was confirmed by the women‘s
complaints (p.106), his ambivalence shows in different case studies. For example, he wanted
to cleanse a woman with borax rather than to build up her body with saffron as the patient
wanted. For medical anthropologists it is relevant to look at such frictions between two
contrary medical belief systems in order to understand their conflicting influence on medical
practice and illness perceptions.
Storch did not make any contribution to the history of gynaecology, not because he did not
physically examine his patients, but because during his time, this discipline and the concept of
‘gynaecology’ did not exist, the womb had not yet become a part of a ‘reproduction system’
(p.28), ‘menopause’ had not yet been “invented” as a concept of physiology (p.118), nor was
the body an ‘unchanging biological reality’ (p.3). Storch simply spoke of
“Weiberkrankheiten” and looked at the entire life story of his patients. Only from the end of
the 17th century onwards were ‘blood’ and ‘milk’ assigned to functional motherhood (p.117).
In the study of the anthropology of the body it is essential to research how body concepts are
culturally constructed and understand the ways in which cultures can interpret ‘corporealities’
as a sign of gender and sexuality.
Historians nowadays acknowledge that medical concepts and epistemologies are culturebound and develop parallel to similar ideas in other science streams. Scholars have been
focusing increasingly on the history of culture-mediated medical concepts. A good example is
William Harvey, who is no longer seen as the discoverer of blood circulation but as one of the
co-creators of the ‘circulation concept’ which established itself around 1750 also in
economics, journalism and natural sciences (p. 27).
Duden devotes an entire chapter of her book “toward a history of the body”, where she
highlights research studies on body perceptions that have taken such approaches in the past. It
seems that these reflect a trend away from the sciences dominated research. The development
of medical anthropology as a strong emerging discipline can perhaps be viewed as an integral
part of this movement, as are patient’s case stories like those of Storch, who had not been
given any importance over three centuries, but have started influencing our thought process
now.
2. Research approaches by Duden
The approaches Duden takes in her study broadens the horizon of any researcher open to
accept that even our present perception of the object of our study (in this case the female
body) is culture-bound and has been mediated by several centuries of the “sociogenesis of the
modern body” (p.3). She acknowledges that the first step in this research study was to
“realise that my own certainties about the body are a culture bias” (p.vii).
Initially, she applied Western categories, by first ordering the case records according to
diseases and the modern anatomical grid or parameters of 18th century science, and learnt
during the research that it would be impossible to “interpret Storch’s notions through Stahl’s
doctrines” (p.104). Medical anthropologist have faced a similar problem with the application
of explanatory models, which are limited when it comes to complex social and political
factors influencing illness perceptions in other societies, but still help in illustrating the basic
concepts. Duden developed a construct which she called “orientational patterns of perception
guiding the doctor’s practice” (p.105), which helped her to bridge the gap in perception across
three centuries.
As we are dealing with women in history, and there are no documents written or recorded by
the women themselves, a broad spectrum of other data had to be used to understand their body
concepts by inference. Duden reached a consensus through a dialectical dialogue between
contemporary sources, secondary literature, Storch’s material and her own ‘orientational
patterns of perception’, which seems an appropriate attempt to come as close to ‘reality’ as
one can possibly get without living oral sources and ethnographies.
Duden realised that she could not apply modern medical concepts to describe or understand
18th century patients’ descriptions. “My own certainties became an obstacle” (p.105) - a
critical self-reflection that should be considered by medical anthropologists as well.
3. The cultural environment that influenced Storch’s medical practice and body
perceptions
Duden presents a biography of Storch, his education, social background and the socio-cultural
and economic situation in Eisenach that framed his professional status in society. These
details are essential for the understanding of the doctor-patient relationships. They are
relevant to medical anthropologists, because they illustrate the strong influence of society and
economics on a medical practice and the relationship between the physicus and the patients,
which would give a different impression if described outside its cultural context.
Storch’s patients are powerful in the decision making of their treatment. Most cases show that
the doctor is consulted not always for treatment, but for advice or a confirmation of a home
remedy. There are always several members involved in the therapeutic process. Apart from
the patient, there are relatives and other doctors from different educational backgrounds and
geographical places. He has to deal with local healers, herbalists and even ‘quacks’. Even
though Storch is considered an authority, he does not have the authority to decide over the
treatment alone. He simply responds to the requests of his patients, which can be
‘observation’, a ‘prescription’, ‘advice’, or ‘agreement’ with a therapeutic measure given by
someone else.
This diverse medical field of therapeutic management is specific to the time and related to
certain socio-economic developments. Medicine was not yet an institutionalised profession
with power. Medical education was not yet uniformly organised at universities. Storch studied
only two years at a university before he ran out of funds. Another major influence on him
studying modern biomedicine was the fact that his father was a local healer, who became
increasingly marginalised and illegal in his practice, as he did not have a licence (p.51).
Economic reasons influenced the shift in medical education from herbalism towards
biomedicine. If his father would have been allowed to work as a local healer, he may have
educated Storch in the family tradition. Sending him into a different medical system was out
of economic need, not out of acceptance of the new system. Modern medicine could develop a
strong foothold, when it was supported by the prevalent power structures, not necessarily by
people’s medical and scientific insights.
It would be important to ask in what way Storch’s family herbalist background, which must
have become embedded in his perception of the body, influenced his understanding of his
female patients. How strong was this childhood influence compared to his short university
studies, which taught him anatomical and mechanic concepts? His family background may
explain why Stahl’s theory influenced Storch’s thinking, but Storch’s perception of the female
body was closer to the perception of his patients when it came to practice (p.106).
Moreover, establishing a medical practice needed strong social connections, letters of
recommendations, licenses from the council or the duke etc., and it took Storch several years
to reach the status of ‘town medicus’ of Eisenach (p.55-6). Duden’s description of the city life
in Eisenach with merchants coming in along with travelling healers and quacks, etc., allows
an understanding of the setting where the consultations took place. There was no health policy
and “public health“ depended on the resident ruler. Court patronage was essential, and Storch
earned it by successfully treating the Duke and the Dutchess (p.59). Storch’s situation shows
that the medical profession was not yet stabilised. The lack of professional authority and
decision making power, in turn empowered his patients to make their own treatment
decisions. Home remedies, self treatment and making choices from a wide spectrum of
available medical alternatives were within the decision power of the patients and their
families. “Mothers seem to have been the real opponents” with a strong influence on the
medicus (p.75). The biography of a physician is essential for an anthropological
understanding of his case records, because it shows how culture-bound the relationship
between the doctor and his patient group can be and how the physician’s power depends on
social establishments.
4. Metamorphosis and Inner Body Perceptions
In the early 18th century Germany, modern anatomy and aetiology had not yet shaped public
body perceptions and the imagination of the inner body was only limited by the contemporary
culture’s conception of the world (p.107). The body was not an object of social control.
Everything “beneath the skin” was seen as fluid and in constant metamorphosis and
movement. For example, the women’s menstruation was not seen as essential for their ‘beinga-woman’ (p.114). Women could bleed from different parts of their bodies and even men had
regular bleedings, e.g. from their piles, from the left thumb at the full moon, or through
varicose veins. The “flow of the piles” was as sensitive as “the monthlies” (p.116-7).
The milk flow that stopped from the breasts could be discharged with urine, and the sweat of
an infant could smell like elderberries because the nursing woman had taken elderberry juice
as a purgative. Wind in the womb could rise upwards, speech could exit from the ears (p.1089). “The doctor’s gaze turned materials that were quite different into one and the same matter,
which he interpreted on the basis of a belief in a continuous inner transformation” (p.109).
The thinkable became a reality (urinating through the mouth) (p.6).The substance seemed to
remain the same, but the fluid world inside the body could undergo various metamorphosis.
These perceptions indeed show, that “matter itself is historical” (Ivan Illich 1985 in Duden
1991:7), and culturally constructed.
From the modern anatomical perspective, it is easy to dismiss the body perceptions of Storch
and his patients as ‘nonsense’ or ‘unreal’. From a medical anthropology point of view they are
important to be taken as ‘real’ within the culture they emerged from. Acknowledging their
culture-specific ‘reality’, we can understand an entire medical and human world that lived and
emerged with such perceptions, and perceive the complexity in this reciprocal interrelationship between culture, human consciousness and body perceptions.
A few decades later, at the end of the 18th century, the ‘gaze’ of the physician changed
considerably through the ritual of clinical examination which resulted in a creation of the
body as a passive object that could be abused, transformed and subjugated. (Foucault Michel
1973, quoted from Duden 1991:3). The development of desection had been culturally and
religiously influenced since the Middle Ages, where anatomy was a public ritual during
executions. This led to deep aversion of the inner body being taken out (p.9) and perhaps a
centuries-long delay in public and cleric support of anatomical studies. Medical anthropology
needs to embrace such vast historical developments to understand medical cultures.
Conclusion
Medical Anthropologists have been pointing out that ‘disease’ the way it is understood today
is not a universal concept, but emerged from our own history and cultural concepts. Duden
brings forth excellent examples from medical history that elucidate the relativity of today’s
dominant biomedical concepts. From her book a cultural spiral becomes visible linking the
time of inquisition, anatomical desections to the era of a quantitative measuring medical
system which has led to the disappearance of the importance of sense, touch and smell, and
metamorphosis of body fluids. Consequently “being ill” has lost its formal meaning of a
personal life event and has become a “deficiency in relation to a medically described norm.”
(p.31). Medical anthropologists have attempted to address the fallacies of such a one-sided
approach.
Duden’s ability to bring back to life the body perception of early 18th century women for the
reader, provokes re-addressing one’s own body perceptions. Especially medical
anthropologists who want to work in the field of non-western medical cultures need to
become more aware of the relativity and cultural constructs of their own sense perceptions
with which they study the perceptions of societies that emerged from very different histories.
We need to be aware that categories we use in medical anthropology today such as sexuality,
kinship, reproduction, family, etc., are 19th century intellectual constructs and developed out
of the late 18th century dichotomy of dividing nature from culture (p.21). The question needs
to be raised if such categories can be used in explaining medical cultures that existed before
these categories were invented.
Duden’s methods in attempting to understand body perceptions so different from her own
show that as a researcher she herself has to undergo a change in perception if she wants to
understand medical practice of a different time and space. This critical reassessment of one’s
own perceptions seems to me a crucial tool to develop for authentic medical anthropological
research.
The Woman beneath the Skin can offer guidelines to medical anthropologists, also in their
study of medical traditions from the East that are being introduced to the West. Duden’s work
proves that any one-dimensional approach would be limiting in understanding illness events
and body concepts in different societies and that great care must be taken to identify the
medical ‘realities’ of such cultures from within their own perspectives.
NOTE
From discussions during the tutorial it became clear that the major point why Barbara
Duden’s work is relevant to medical anthropologists is that her ethnography is a unique record
of that time, and the first contribution of a feminist historian towards the understanding of 18th
century female body concepts through case records, filtered through the perspective of the
physician.