Waiting in Premodern Medicine

Lina Minou reflects on the role of waiting for early-modern patients and practitioners

Waiting for medical care has a past. It did not happen within well-lit rooms and within typified time limits, but happen it did. To recover it, as much as possible, we have to recognise the broader patterns and scripts within which it arose.

Waiting, in the margins

A broadside of 1689 advertises the capacities of a physician, recently settled in London, in treating an impressive array of ailments (Anonymous 1689). The first page of this publication is taken by a large image of a receiving-and-examining room, well-stocked in medicine-jars covering walls from floor to ceiling. Central to this picture is a queue of people waiting to be seen by the doctor-figure in the middle.[1] Most are standing, others, weakened by illness or injury, are shown lying down. Some hold glass jars of urine samples (commonly used for diagnosis), presumably their own, but they may be servants who have brought their masters’ samples for inspection (Bylebyl 1990).

In some ways this image is immediately recognisable. It shows patients waiting for care, a situation we increasingly find ourselves in and for longer and longer periods. Yet the image is not self-consciously depicting the act of waiting in itself. The image, and the text underneath it, serves to market the services of this medical professional to the public. The waiting shows the demand he is in, a nod to his skill. The text promises relief, not abstractly, but by multiple references to people who were cured, some of them after years of suffering implacable diseases that many other doctors could not alleviate. The wait for cure, the text seems to imply, is over.

While waiting was certainly a reality for patients of the past, the experience of waiting can only be indirectly recovered. Many early depictions of patients waiting – for diagnosis, treatment, surgery – arrive to us from the margins. Medical miniatures, found in early manuscripts, show medical procedures such as uroscopy (diagnosis on the basis of urine colour), bloodletting, or surgical procedures.[2] The medical professional performing these procedures and the person on whom it is being performed are central. Other figures, where they exist, are secondary, often representing students. In some cases, though, they clearly are patients, waiting for the same task, or to undergo the same procedure. Their waiting is not explicit; it is implied in their being included in the depiction and confirmed by cues (obvious injuries, pained expression, holding common paraphernalia). Even when waiting takes much of the visual space, as happens in the 1689 image described above, it is still subordinate to the centrality of the practitioner; the queue is there only as an illustration of his skill.

Today, we consider medical-related waiting a phenomenon worthy of analysis on its own. It is recorded, followed in its fluctuations, quantified and measured, and used to gauge service performance. In the context of healthcare as social good, waiting is a material form of equity; we all have to wait for our turn as we share finite resources. Waiting can also be a barrier. Backlogs lead to delays in care that, in turn, may result in deterioration. Waiting – as a preamble to accessing care, as a problem to solve, as time ‘lost’, ‘tolerated’, or painfully endured – can be at once a signifier of justice and, through its uneven allocations, a sign of social disparities. However it is experienced, medical-related waiting is perceived as a condition of modernity, arising from and within professionalised and systematised forms of medicine.

As the many figures in the broadside illustration reminds us, though, such waiting does have a past. Past forms of the waiting experience lack structure, or the particular structure we are accustomed to, because they depend on other forms of access to care. Equity of access and justice bear on that past experience of waiting as well: as noted above, there may be figures, like servants, that wait on behalf of others. To understand and recover, as much as possible, medical waiting of the past we have to recognise the various contexts, medical scripts, and the social situatedness within which it arose.

Waiting, in the presence of others

For early-modern patients access to treatment, to physicians, and other healers was prescribed and delimited by one’s social circumstances. The upper echelons of society could have access to a family physician, of formal education and of a certain social status as well. For others, healthcare could mean anything from turning to a traditional remedy offered by a woman with empiric experience only, to seeing an itinerant physician who advertised their services. In other words, much of what we would today term access to healthcare was not a matter of systematized use of a social service, but a matter of opportunity: people looked for recourse to the forms of care that were available, and affordable, to them.

In that sense, their waiting was also haphazard, difficult to pre-empt temporally and spatially. It occurred with the decision to seek help, its duration was difficult to anticipate, and, significantly, it was communal.  One waited in the presence of others, which means that waiting was also witnessing: the ailments and diagnoses of others, the pain and emotions of others, the details of the same procedure one was about to undergo. Waiting, in this sense, was bearing testimony: to the skill of the physician, to the very progress of disease, to the reactions of other patients. In short, to the art and science of medicine itself.

Such an experience would have helped instil, to the minds of lay people, forms of knowledge about medicine and the body. Instead of ‘empty’ time, then, waiting can be seen as contributing to the shaping of a common framework for health and illness, shared by lay and learned people. Many other factors contributed to this: the longevity of the humoural paradigm in medicine; its embeddedness in everyday life through practical advice on health management and preservation; and relevant printed works available in the vernacular.[3]

Waiting, in anticipation of Nature’s course

When they did not wait in a queue, patients waited for signs: signs of disease progression and of recovery. In recovery the role of nature was paramount. As Hannah Newton shows, nature was part of a matrix of healing agents and processes (Newton 2015). The physician was also an agent of recovery, bound in an ambivalent power dynamic with nature: recovery could be attributed either to letting nature take its course, or to the physician’s decisive action (Newton 2015). This meant that there were times when the physician subsumed his skill, and himself, into that of nature. A time, that is, when one had to wait. As the Scottish physician John Macollo (c.1576–1622), explained:

[…] For if Nature be strong enough to overcome the sickness, then the Patient shall escape; but if she be so weak that she cannot obtain the victory, death then of necessity must follow; and the Physitian must wait on the one or the other sooner or later, according as the spirits are stronger or weaker. (Macollo 1659, 43)

From our viewpoint, used as we are to care as intervening, acting upon the body, waiting may be seen as inaction or failure. But this was not about surrendering. ‘Nature’ was not so much a cosmological abstraction, but signified a ‘bodily agent, working intelligently to heal the body’ (Newton 2018). Waiting, then, signified the knowledge to recognise when further action was futile, or even harmful. This included the responsibility of convincing patients to wait. Theophile Bonet (1620-1689) urged physicians to ‘comfort’ and ‘exhort’ patients, ‘to make no more haste than good speed, and to wait Nature’s time’ (Bonet 1686, 183). He added: ‘This rash and impatient thinking in sick People hinders the Cure’ (Bonet 1686, 183). References to waiting for ‘the time of the cure’, or for ‘Nature’s time’ recur in early-modern medical publications. They signify the skill of practicing waiting, of discerning its necessity, of making it part of care and cure. Physicians and patients shared the notions of health and illness that recommended and justified it.[4]

***

References to waiting occur in many other ways within medical texts of the past. For instance, there are references to the long time patients waited without comfort before seeing a physician, or before receiving the correct type of treatment. These comments were probably purposeful and strategically made to emphasise the professional superiority of physicians to other, empirical, healers. In other instances, they betray intra-professional antagonism between physicians of different dogmas,[5] and later the gradual abandonment of the humoural paradigm.[6]

Waiting can also be seen as part of a nascent professional medical identity. Daniel Sennert (1572-1637), advising on proper ways of taking the pulse, did not simply describe actions, but spoke to the sensibility that would allow the physician to decipher the body. ‘That a pulse may rightly be perceived’, Sennert writes, an ‘exquisite sense of feeling’ and a ‘soft hand’ are necessary, as is the skill of knowing when to wait for the most suitable moment to touch the patient’s wrist (Sennert 1658, 166).[7] If we learn to look for it, then, waiting in medical history is not as marginalised as it first seems. Rather, it is revealed as part of the principal experiences of medicine: endured, but also practiced by doctors and patients alike.

Acknowledgements:  My thanks to Professor James Wilson, Department of Philosophy UCL, and Dr Daniel Herron, NIHR UCLH BRC, whose work and interest into waiting for care in contemporary settings prompted me to search for historical parallels.

Dr Lina Minou (@Minou1Lina) is a Research Fellow at the Department of Philosophy, UCL, currently completing a project on phenomenological perspectives into the waiting experience in healthcare. She has a keen interest in the history of medicine and the ways insights from the medical past can help shape dialogue on contemporary concerns around health and illness.

Notes

[1] The image I describe in the first paragraph is from the 1689 broadside publication, held at the British library (ESTC no: R231163). The sources I refer to are early printed works of medicine and are  accessible through the Early English Books Online (EEBO) and Eighteenth-Century Collections Online (ECCO) databases.

[2] The image accompanying this essay is one such example and comes from Loren Mackinney’s work: MacKinney, Loren C., and Thomas Herndon. 1965. Medical illustrations in medieval manuscripts. Berkeley: Univ. of California Press. The compilation is a great source into early medical illustration and is available to search here: https://dc.lib.unc.edu/cdm/landingpage/collection/mackinney/

[3] I do not suggest here identical understanding between popular and learned medicine, but the existence of shared beliefs about the body, health, and illness. For an overview of medical knowledge and practice in the early-modern period see: Lindemann, Mary, 2010 (first publ. 1999). Medicine and Society in Early Modern Europe, 2nd edn. Cambridge: Cambridge University Press; Stolberg, Michael, 2011. Experiencing Illness and the Sick Body in Early Modern Europe. London: Palgrave Macmillan.  For more information on the Hippocratic-Galenic medical tradition, see: Temkin, Owsei, 1973. Galenism: Rise and Decline of a Medical Philosophy. Ithaca NY: Cornell University Press; Ballester, Luis García, 2002. Galen and Galenism: Theory and Medical Practice from Antiquity to the European Renaissance. Burlinton, VT: Ashgate, 2002.

[4] Such waiting is not abstract, but shaped according to the form of disease: for instance, patients and doctor both knew to wait for the moment of ‘crisis’ when the cure was to achieved by purging. See Newton, 2018, 53 for more details.

[5] For examples of this, see the works of Helmontian physician Everard Maynwaringe (c. 1629-1713). On the marketplace of medical publications in the vernacular and professional antagonism see Fissell, Mary, 2007. ‘The Marketplace of Print’, in Mark Jenner and Patrick Wallis (eds), Medicine and the Market in England and its Colonies, c. 1450–1850. Basingstoke: Palgrave.

[6] For an understanding of transitions and continuities between early modern and eighteenth-century medicine, see Wear, Andrew, 2000. Knowledge and Practice in English Medicine, 1550–1680. Cambridge: Cambridge University Press.

[7] On the sensibility of the practitioner see: Vila, Anne C., Enlightenment and Pathology: Sensibility in the Literature and Medicine of Eighteenth-Century France. Johns Hopkins University Press. For an appreciation of the connections between emotion, empathetic practitioners, and the changing role of emotion in medicine and medical experience see also Bound Alberti, Fay, 2006 (ed). Medicine, Emotion, and Disease 1750-1950. New York: Palgrave Macmillan.  Michael Brown’s and Agnes Arnold-Forster’ work on the project Surgery&Emotion focuses on a later period, but is crucial in understanding the development of the phenomenon and the role of the emotion in the cultural transformation of the medical professional identity, freely accessible here: http://www.surgeryandemotion.com/publications

Works Cited

Anonymous. 1689. By the King and Queens Authority. These are to give notice, that here is lately arrived an experienced and most famous High-German doctor, who by his great study, and constant practice in several parts of the world, as well in princes courts as in hospitals, and war-like expeditions, hath obtained such a physical method, as to cure all external and internal distempers (if curable): London, s.n.

Bonet, Théophile. 1686. A guide to the practical physician shewing, from the most approved authors, both ancient and modern, the truest and safest way of curing all diseases, internal and external, whether by medicine, surgery, or diet.: London, printed for Thomas Flesher.

Bylebyl, Jerome J. 1990. “Interpreting the Fasciculo Anatomy Scene.”  Journal of the history of medicine and allied sciences 45 (3):285-316. doi: 10.1093/jhmas/45.3.285.

Macollo, John. 1659. XCIX canons, or rules learnedly describing an excellent method for practitioners in physick / written by Dr. J. Macallo [sic], physitian in ordinary, first to Rodolphus, late Emperor of Germany, and after his death, physitian in like manner to K. James: London, J. Grismond.

Newton, Hannah. 2015. “‘Nature Concocts & Expels’: The Agents and Processes of Recovery from Disease in Early Modern England.”  Social History of Medicine 28 (3):465-486. doi: 10.1093/shm/hkv022.

Newton, Hannah. 2018. Misery to Mirth: Recovery from Illness in Early Modern England. Oxford: Oxford University Press.

Sennert, Daniel. 1658. Nine books of physick and chirurgery written by that great and learned physitian, Dr Sennertus. The first five being his Institutions of the whole body of physick: the other four of fevers and agues: with their differences, signs, and cures: London, printed by J.M. for Lodowick Lloyd, at the Castle in Corn-hill.