Epilogue: Airs, Waters, Places. A Status Report

When I teach a course in medical history, I often refer to an “airs, waters, places tradition.” It is a reference, of course, to a particular Hippocratic text—and a shorthand way of acknowledging historical continuities in our understandings of the interaction between place and person in determining health and disease. It is a conceptual tradition that saw the body not only as situated in place, but as a continuously processing entity, always at risk as an aggregate of those elements in the natural world that sustained it. The Hippocratic era was a time, in the carefully chosen words of Shigehsha Kuriyama, “when the body represented something

quite different from the entity that we imagine now—a discrete given, an independent and isolated object. Once upon a time, all reflection on what we call the body was inseparable from inquiry into places and directions, seasons and winds. Once upon a time, human being was being embedded in a world.¹

This classical body was situated, not abstracted and generalized, as it has so often become in the postlaboratory era. Airs, Waters, Places (hereafter AWP) assumes a holistic and integrative—one might call it both ecological and sociological—vision, understanding human beings not only as potential patients, but men as citizens and soldiers, and women as their differentially fecund mothers. Environments are seen in this ancient treatise through an inquiring physician’s eye. The text begins in a clinician’s voice, but a clinician who is an obligate climatologist, geographer, political scientist, and ethnographer as well as healer, a clinician urging the necessity for understanding peculiarities of place in evaluating and treating patients.²

The author or authors of AWP assumed that the body managed its ongoing interactions with the environment through natural—inbuilt—mechanisms. Even beginning students assigned to read this seemingly archaic treatise note the way it refers in casually secular and material terms to the role of humors and tensions in processing inputs from the external world and thus shaping sickness and health. Particular configurations of soils and wind, season and climate produce particular patterns of morbidity and mortality, temperament and physique. Children grow and mature, sicken or thrive. Populations increase or decline in response to the characteristics of their environment.

This style of explanation turned on a central irony: everything necessary to life was at the same time an occasion of vulnerability—wind, climate, water, food. Geography was in this sense destiny, providing indispensable components of existence. Elements of this inclusive and interactive way of thinking about physiology and pathogenesis remained widespread in Western medicine through the seventeenth and eighteenth and into the nineteenth centuries. It was the will of “GOD, the Governour of all Things,” as Thomas Sydenham explained, “that Human Nature should be fitted to receive the various Impressions that come from abroad, it could not be, but it must be subject also to many Diseases.”³ It is not surprising that scores of earnest physicians and clergyman in the late eighteenth and nineteenth centuries kept careful records of temperatures and barometric pressures and sought to correlate them with health and disease.⁴

The nineteenth-century movement for public health reform was justified in just such terms—linking environment, physiological process, and cumulative outcome. For mid-nineteenth-century reformers in public health, local environments provided both explanation and solution for the shocking differentials in mortality and morbidity that marked country from city, townhouse from tenement, the holds of ships or crowded military camps from farm or village.⁵ An epidemiology of microenvironments served as an effective basis for a reformist public medicine. Why was it healthier to live in the country than the city? Why did the confined air of hospitals, tenements, and troopships produce so many fevers and infections? Why did professionals live longer than laborers? Class too reflected the peculiarity of local circumstance. The constitution of a particular woman or man embodied both environment and individual regimen (the latter a choice for the wealthy, a constraint for the poor). It was simply assumed, for example, that the quality of the air one breathed, like the food...