Abstract
James Lorimer Halliday (1897–1983) pioneered the development of the concept of psychosocial medicine in Britain in the 1930s and 1940s. He worked in Glasgow, first as a public health doctor, and then as part of the corporatist National Health Insurance scheme. Here he learned about links between poverty, the social environment, emotional stress and psychological and physical ill-health, and about statistical tools for making such problems scientifically visible. The intellectual development of his methodologically and epistemologically integrated medicine – a hybrid of biomedical and psychological approaches – was embedded in the context of this practice with its particular medical culture and socio-economic circumstances. Halliday’s ideas are part of the wider, heterogeneous turn towards medical modernism and holism within mainstream medicine in Britain, western Europe and the United States in the inter-war period, and their evolution underlines the varied nature of contemporary anti-reductionist thinking in medicine. It also points to the diversity of the sources of holism and the many routes by which psychological and especially psychosocial discourses about health and illness entered professional and public arenas in Britain in this period.
James Halliday, physician, public health doctor and psychoanalyst, who graduated MB, ChB from the ‘Glasgow School’ of Medicine in 1920 (Jacyna, 1988; Smith and Nicolson, 1989; Hull, 2007), pioneered the development of concepts of psychosomatic, and especially psychosocial, medicine in 1930s and 1940s Britain. Halliday developed a methodologically and epistemologically ‘integrated medicine’ (Halliday, 1948: 209) – a hybrid of biomedical and psychological approaches, shaped by the social contexts of his medical education and evolving practice. Just as, for Halliday, disease was produced by the physically mediated emotional stresses of life lived in specific conditions, so his new medicine was similarly historically specific, bearing the marks of a particular medical culture and set of socio-economic circumstances. Halliday’s ideas are part of a wider, heterogeneous turn towards medical holism within mainstream medicine in Britain, western Europe and the United States in the inter-war period, which underlines the variety of contemporary anti-reductionist thinking (Lawrence and Weisz, 1998), the diverse sources of holism, and the many routes by which psychological (and psychosocial) discourses about health and illness entered professional and public arenas.
1 The meanings of the psychosocial and the historiography of holism
Today ‘psychosocial medicine’ has fragmented into a broad spectrum of disciplinary sub-specialties and meanings (Herrmann-Lingen et al., 2004). This is an index of the centrality of the bio-psycho-social paradigm to contemporary medicine (Freeman, 2005), a status itself indicative of the profession’s acceptance of reductionist critiques of biomedicine.
Yet in the late 1920s, Halliday began developing a concept of psychosomatic medicine as a radical alternative to perceived failures of a biomedical model still far from maturity. He hoped that:
The doctor of the mid-twentieth century … adopted the approach called Psychosomatic Medicine … which emphasises that it is the person – not a part, nor an organ – that is ill; and that many common bodily disorders remain inadequately understood if the patient is examined and considered only as a body (or soma), and not also as a ‘life’ (or ‘living soul’, or psyche). (Halliday, 1949: xi)
Halliday argued that when the irresistible force of emotional stress (originating in frustrated childhood instinctual drives) hit the immovable object of traumatic life-events (like unemployment) physical illness was often the result. Such psychosomatic illness was the main cause of incapacity for work. Moreover, it was a sign, not just of a sick individual, but also of a ‘sick society’. Social change had been so intense since c.1870 that society’s equilibrium had been upset. Old structures had disintegrated and new organizational patterns and rhythms were unnatural. In a machine-like, rationalized, bureaucratic society where thought, and even people, were endlessly divided into specialized compartments, nobody could express emotional potential by understanding and fulfilling a social purpose. This produced social disintegration (strikes, absenteeism, ultimately war) and psychosomatic illness. Doctors and governments should factor psychological as well as physical aspects of the environment, and biological impacts of state action in perpetuating a certain kind of society. As an integral part of this society, medicine too was infected. Doctors were servants of the machine-state; certifiers of what constituted illness, they kept the administrative/economic production line going. Medicine – once human, holistic and individualized – had disintegrated into specialties that dealt only with parts of the body-machine. The solution was a new ‘biopolitics’: state-sponsored intervention in material conditions and (thus) their emotional correlates, rooted in a new integrated, holistic medicine (Halliday, 1948: 213).
In Harrington’s recent typology of narratives of evolving mind/body medicine, Halliday could be characterized as conflating the ‘body that speaks’ (illness as repressed trauma) with ‘broken by modern life’ (illness as somatized emotional stress) (Harrington, 2008). However, Halliday’s holism was not simply a product of the general diffusion of psychological ideas from psychological into physical medicine, and thence into public understandings of the self (Smith, 1997); it was also rooted in particular Glaswegian ways of medical thinking and working.
Amid the general inter-war depression, there was a boom in this kind of anti-reductionist, anti-materialist, anti-atomistic and anti-positivist thinking; a general intellectual questioning of the nature and scope of authoritative knowledge about external reality both in the arts and in the sciences. In the sciences this led to anti-causal physics (Forman, 1971), in the arts and humanities to modernism and phenomenology, and in medicine to a broad range of holisms which sought to reconceptualize Cartesian dualism (Hughes, 1958; Ross, 1994). A common focus was abandoning the cell as medical unit of analysis, to view the body as an interdependent, self-regulating, adaptive, stable system (with harmonious sub-systems) interfacing with external environments. Often holism included a conception of the ‘mind’/’body’ relationship, but there were many takes on this, from symbiosis to complete fusion. Holistic thinking sometimes contained corresponding arguments for reform of medical knowledge and practice along interdisciplinary lines (Young, 1998: 239–40). As Lawrence and Weisz (1998) have argued, medical holism also contained either ‘cultural’ (or what Ross terms ‘aesthetic’) and cognitive components (Ross, 1994): a rejection of positivism combined with uncertainty about the moral basis of the mass society of the machine age, along with intellectual relativism and sensitivity to the limitations of scientific knowledge’s objectivity claims. All of these possible characteristics (and more) were mediated by national and local general public, political, professional and medical cultures to produce a host of localized holisms (Timmerman, 2001; Harrington, 1996).
The existing historiography of British interwar holism characterizes it as a cultural phenomenon tending ‘towards pragmatic reformism’ (Lawrence and Weisz, 1998: 7) and devotes most attention to elite London consultants, who argued for the art of integrated body/mind medicine as part of a wider professional dispute with laboratory science (Lawrence, 1985, 1998). The vehemence of this (partly rhetorical dispute) has been exaggerated by the historiographical hegemony of the idea of binary opposition between laboratory and clinical ways of thinking and working, rooted in an uncritical use of the special pleadings of the historical actors (Hull, 2007).
Halliday’s medical holism was different. It was rooted in a particular medical culture – the anti-reductionist medicine of the Glasgow School with its intellectual and institutional traditions of clinical primacy (Smith and Nicolson, 1989). Yet, in common with much holistic thinking, it did not reject scientific methodologies, but redeployed them to materialize new kinds of (statistically analysable) social scientific facts and bring them within a broader conception of medical explanation.
Hayward (2007) and Thomson (2006) argue that an important context for medical holism was the increasing influence of psychological ideas on mainstream physical medicine. This psychologization helped shape not only the professional identity of general practitioners, but also perhaps the character of British medical holism itself. Halliday’s new medicine did later become immersed in Freudian and Jungian concepts, but, just as for Lawrence’s elite London clinicians (1985, 1998), Halliday’s holism came from his underlying philosophy of medicine; this is why he sought out psychoanalytical training, and not vice versa. As his obituarists noted: ‘the notion that a public health officer should also be a practising physician, and that the latter should also be a competent psychotherapist, was to Halliday self-evident and, indeed, central to his holistic view of medicine’ ( BMJ, 1983).
This article argues that the genesis and evolution of Halliday’s thought can best be understood as arising out of his milieu: a Glasgow-trained and practising doctor, alive to contemporary local, national and UK debates about the nature and scope of medicine. Local medical cultures mediated the development of the variety of contemporary British medical holisms, just as in Europe and elsewhere. Such holisms arose in the same way, and for the same context-dependent reasons that this period saw the contingent construction of new versions of ‘scientific medicine’ (using laboratory-based ways of working and thinking) and also of social medicine (Hull, 2007; Porter, 1992, 1996). These developments took place in the characteristic contemporary socio-economic contexts of unemployment and ‘distressed areas’, of increased state–medical corporatism, of debates about the extension, nature and scope of future medical provision, and a focus on preventive medicine. 1 There was also an intense professional power struggle within medicine centred on the definition and control of experimental medicine, and especially of clinical research (Hull, 2007, 2001; Lawrence, 2005).
Within these contexts, the concept of ‘holism’ was mobilized by different groups for different rhetorical, professional and political ends. Moreover, local medical cultures and other local influences shaped local variants of medical holism. The terroir shaped knowledge and practice, according to the same model that Halliday himself applied to disease aetiology: a symbiotic, diachronic process of individual–environmental interaction. This article will propose that the causes of his psychosocial turn are to be found in the relations between Halliday and his Glasgow context. Applying his methodology to his medical holism – asking ‘What kind of doctor becomes a psychosomatic and psychosocial doctor now?’ – exposes its complex, context-dependent and contingent roots. The evolution of Halliday’s thinking will be explored as it developed: in the crucible of his ongoing influences. 2
2 Doctor Halliday, my patient: Career and development of ideas, c.1920–48
After Glasgow University, Halliday went to St Andrews as a general practitioner’s assistant, when James Mackenzie’s (1853–1925) Institute for Clinical Research was active. Mackenzie pioneered longitudinal studies of disease, arguing that general practitioners could make special contributions to aetiology and epidemiology given their proximity to early-stage disease and their long-term relationships with patients. Local GPs saw their National Health Insurance (NHI) panel patients at the institute, where laboratory investigation facilities were provided. Here Halliday said that he first ‘came to appreciate the value of group practice and also of clinical research’ (Halliday, n.d.[a]: iii). He also grasped the special contribution only GPs could make to unravelling origins and causes of disease through natural history and epidemiology: intimate knowledge of the patient’s constitution and lifestyle over time, and thus of predisposition to disease (J. MacKenzie, 1919; Macnaughton, 2002).
In his next post (1922–4) as resident physician at Ruchill Municipal Fever Hospital, Halliday began to digest his St Andrews experiences: ‘I slowly came to assimilate the conception of a disease not as a thing but as a vital reaction of the whole individual in response to external stimuli’ (Halliday, n.d.[a]: iii). In addition to his clinical duties, Halliday also became engaged in routine bacteriological and biochemical laboratory work at Ruchill’s Laboratory. His 1925 Glasgow University MD thesis reflected his laboratory-minded side. His new biochemical research showed the existence of a delayed cerebro-spinal fluid sugar curve, and that raised sugar was not diagnostic of epidemic encephalitis lethargica (Halliday, n.d.[a]: iii) – a characteristically Glaswegian hypercritical re-examination of the diagnostic validity of a laboratory test (Halliday, 1925a, 1925b).
The local expert on encephalitis was the physician Ivy Mackenzie 3 – close friend of James Mackenzie – who argued in 1927 that the progress of disease involved bodily adaptations to initial injury or infection. Medicine was ‘concerned … with … the human subject, striving to preserve its identity in adverse circumstances’ (I. Mackenzie, 1927: 524). Mackenzie argued that the ‘existence of emotional states associated with fear, anxiety and pain is invariably accompanied with disorder of internal secretions’ – e.g adrenalin and histamine – which can affect circulation and thus tissue viability. Underlying ‘nervous instability’ or ‘morbid concentration’ on affected parts made certain individuals more susceptible to progressive disease (I. C. K. Mackenzie and I. Mackenzie, 1943: 72, 73). This position informed Halliday’s basic aetiological framework. Drawn to the social by his ensuing public health career trajectory, he explored the roots of that initial nervous instability that made certain individuals more susceptible to disease. Halliday addressed social causes of what he called, using identical language to Mackenzie, ‘tensional states’: ‘“emotional constellations” compounded of various proportions of fear, rage, hate, grief, guilt … and from the somatic point of view they are seen as particular muscular, vasomotor, visceral, and secretory changes’ (Halliday, 1948: 103–4).
Halliday’s public health work gave him broad and deep knowledge of local patterns of illness and medical provision. 4 From 1924 to 1926, he was a Glasgow Corporation tuberculosis officer, concentrating on epidemiology. He then held senior local authority health administration posts: from 1926 to 1929 as South Glasgow’s medical officer for public health and sanitary services; then as the Medical Officer of Health’s (MOH) senior assistant from 1929 to 1931. During this period Halliday noted that he ‘learned both from field experience and statistical investigation the profound effect of physical environment (housing, feeding, clothing, sanitation, infestation, and poverty) on the incidence of disease’ (Halliday, n.d.[a]: iii). Halliday’s department had a strong intellectual and practical tradition of environmentalism: MOH Alexander MacGregor was a pioneer of municipal public health schemes (MacGregor, 1967) and prevention was ingrained in Glasgow medicine more widely (e.g. Cathcart and Ferguson’s work on socio-economic causes of rickets) (Morris, 1922: 336–7). Halliday’s early publications (on epidemiology, aetiology and statistics, the natural history of disease, and subjective symptomology) show that his thought and interests developed naturally out of these work experiences (Halliday, n.d.[a]: iii).
In 1931, his appointment as Regional Medical Officer (RMO) 5 adjudicating national insurance claims put him ‘into direct contact with the problems of Industrial and Insurance Medicine’ (Halliday, n.d.[b]: ii). Between 1931 and 1939 he examined and assessed over 20,000 people. The material and administrative procedures and institutions of contemporary health and welfare provision acted as a machine for making psychosocial forces and afflictions visible (Hayward, 2009). Halliday also took the opportunity to carry out independent researches on this clinical material: one on miners’ illnesses, and the other on health effects of unemployment. He considered that ‘This experience provided me with a synoptic view of morbidity and disablement among workers of all kinds in the industrial and agricultural areas of South West Scotland’ (Halliday, n.d.[b]: iii). Halliday found that, on returning to general medical work, he saw the characteristic disorders presented with:
… fresh eyes so to speak, my outlook on disease having undergone a change as a result of my training in preventive medicine with its dominant emphasis on aetiology. Almost instinctively I applied myself to find answers to questions which I had so often asked when investigating a case of infectious diseases: when did he fall ill? Why did he fall ill at that time i.e. to what stimulus was the illness a response? Why did he fall ill in this way and not another? (Halliday, n.d.[a]: iii: 2)
However, he made little headway until he paid attention to the ‘emotional upsets’ of the patient’s life and ‘external events which precipitated them’. Environmental factors causing deep emotional frustrations, like unemployment, debt and high rates of sickness benefit (compared with wages and unemployment benefit), were clearly involved in producing debilitation. However, in spite of the full application of the unusually well-equipped Glasgow Regional Examining Office with its diagnostic facilities and specialists available ‘for every region of the body and yet no definite change of structure could be defined … this … drew my attention to the problems and prevalence of functional neurotic illness’ (Halliday, n.d.[a]: iii: 2). Reviewing the work of the RMO in an address to the Glasgow Insurance Faculty in early 1934 he observed that:
The old mechanical theories of medicine are being altered … man is more than a body; he is also a mind or, more properly, he is unity of body and mind – a biopsychic organism. Mental stresses and maladjustments have an effect on bodily functions. A man from the mechanical point of view may be organically sound, and yet, because of the effects of mental stress he may be unable to work. … In my experience as a medical referee I find that a considerable number of the persons I examine are disabled because of psychoneurosis. Many of these are labelled on the medical certificate to be suffering from gastritis, anaemia, or rheumatism. Examination shows no evidence of these affections, but the patients are genuinely ill. The bodily organs are sound, but fear or anxiety have affected the mind in such a way that symptoms of physical distress have appeared such as pain, palpitation, giddiness, weakness, dyspepsia, etc. (Halliday, 1934: 264)
There were no structural organic alterations; anxiety, provoked by distressing life-events, had caused mental breakdown which mimicked symptoms.
Halliday’s evolving aetiological view of incapacity was also framed by his reading in Freudian psychoanalysis, like Purves-Stewart’s The Diagnosis of Nervous Diseases (1924) and Kretchmer’s Text Book of Medical Psychology (1934) (Halliday, 1937: 269). In 1935, in his first study looking for psychoneurotic illness, he examined 1,000 insured persons and found a 33 per cent incidence of chronic ailments, with ‘such “labels” as anaemia, debility, gastritis, rheumatism, etc. … used as a cover for anxiety states’. He concluded that: ‘psychoneurotic illnesses provided the largest single “reason for incapacity”‘ and until this was recognized, no effective preventive policies could be attempted involving ‘altering social environment in its psychological aspects’ (Halliday, n.d.[a]: iii [2]) He identified unemployment as the main cause of the functional nervous disorder or ‘pyschoneurosis’ which was at the root of many applications for NHI sickness incapacity certification. Knowledge of such disorders and their aetiology had only emerged after the First World War in the UK, and most currently practising doctors had little knowledge of their role in disease (Halliday, 1935). Age and experience taught the doctor the ‘impacts of circumstance’ and he or she eventually became ‘an unwitting psychotherapist’. Halliday, influenced by Mackenzie, focused on the GP’s special role in early detection of psychological precedents of physical illness.
Halliday ended the paper outlining his new belief that every disorder was accompanied by fundamental biochemical and biophysical change, but that there were differences in the hierarchy of primary causes which indicated a difference in treatment (Halliday, 1935: 88). He was developing the idea of ‘psychosomatic affections’; psychological stress as a direct cause of certain characteristic ailments, rather than mimicking their symptoms with no underlying organic changes.
During 1937–9, as RMO, Halliday was involved in the wider Department of Health for Scotland (DHS) ‘long-term incapacity for work’ study (HMSO, 1943). This aimed to discover main causes of long-term sickness and what help RMOs could give, either by providing second opinions or securing diagnostic inputs from specialist consultants and the remedial input of local rehabilitation services. An experimental teamwork procedure was developed with cooperation between insurance companies and NHI panel GPs. Approved societies would report to RMOs insured cases continuously incapacitated for 13 weeks and not in hospital, and panel doctors would send reports on the patients’ condition and history. In one fifth of 50,000 cases examined, the RMO examined the patient or obtained specialist consultation. Halliday’s hand was also clearly visible: of the 1,000 cases in which data were specially analysed, 83 were given a main diagnosis of psychoneurosis. Moreover, while neurosis was treated as a separate type of complaint from physical ones, tellingly the report stated: ‘the cases classified as psycho-neuroses did not by any means exhaust the number in which there was a psycho-neurotic element’ (ibid.: 12). The psychological aspect was also considered an integral part of rehabilitation schemes (ibid.: 9).
Halliday worked on these data in a special DHS study for his own 1937–8 papers on psychological factors in rheumatism (Halliday, 1937). He argued that the increase in numbers by one third in the past five years was entirely due to those disease labels that could be explained in terms of psychosomatic illness (Halliday, n.d.[a]: iii [2]–iii [3]) – and concluded that rheumatism could not thus be understood or adequately treated without adding a psychosomatic approach to physical concepts of aetiology (ibid.).
Halliday’s evolving aetiological thought, shaped by the early formative environment of the medical holism and clinicalism of the Glasgow School, and his public health and incapacity work, came to stress emotional factors in disease, as correlations between hard lives and bad health were drummed into him by his everyday public health work in the city. This now led him to pursue further his developing interest in psychology and from 1936 to 1939 he was honorary physician to Glasgow’s Lansdowne Clinic for Functional Nervous Disorders, where he first began to appreciate ‘the contribution to general and preventive medicine likely to be made by medical psychology’ (Halliday, n.d.[a]: iv). As he noted in c.1948 about the influence of this period on his mature ideas: ‘The application of psychological knowledge to the interpretation of vital statistics convinced me that many of the illnesses of social groups (and of their members) could not be understood, nor prevented, in the absence of this approach’ (Halliday, n.d.[b]: iii).
Halliday continued to read American psychologists, especially those like Flanders Dunbar and Weiss and English who were developing their own ideas of ‘psychosomatic affections’. As he noted later, they had demonstrated ‘that the physiological dysfunctions induced by emotional upset could, if prolonged, lead not only to the neurotic bodily disturbances but also – at least in certain constitutionally disposed persons – to actual organic change, as in peptic ulcer, the hypertensive diseases and exophthalmic goitre’ (Halliday, n.d.[a]: iii 2). Halliday took these ideas and applied them to the investigation of rheumatism. In a series of papers published in the UK and America, he argued not only ‘that neurotic pains were mistaken for rheumatism but that examples of “true rheumatism” such as fibrositis and rheumatoid arthritis were causally related to the emotional life’ (Halliday, n.d.[a]: iii 2).
2.1 The Second World War: The Emergency Medical Service and the Clyde Basin Experiment
Halliday’s psychosomatic and psychosocial aetiological ideas were reinforced and developed by his Second World War experiences. Halliday was on the Regional Hospital Officer’s staff in the Emergency Medical Service (EMS) – established in 1937 as the first national general state medical service, in anticipation of mass air raid casualties (Dunn, 1953: 6). In 1942, he returned to clinical work as consultant psychologist ‘in psychosomatic medicine to a large Emergency Hospital to which, under a special departmental scheme, sick war workers were being admitted’ (Halliday, n.d.[a]: iii 3; n.d.[b]: iii). Halliday was part of the Clyde Basin Experiment: one of numerous wartime corporatist schemes translating social medicine into practice (HMSO, 1943: 7). In early 1942, increased concern with workers’ productivity led to a DHS scheme to prevent health breakdown, especially in young workers. Targets mirrored the lessons of the First World War, focusing on tuberculosis, infectious diseases and nutritional disorders, but with a new emphasis on anxiety states, as leading not only to fatigue and breakdown, but also to ‘lowering general health and resistance’ (ibid.: 20).
Local GPs and Local Authority tuberculosis officers, and also private industrial medical officers, were invited to refer cases of concern to consultants for admission to EMS hospitals. Here patients had a full medical investigation at the RMS centres to distinguish early organic disease of direct physical origin from neurotic signs. Then patients were sent either to convalescent institutions or to large EMS base hospitals at Law and Killearn for assessment by a panel of consultant specialists (HMSO, 1943: 20).
The scheme was initially restricted to workers under 25 in the densely populated Clydeside area (counties of Renfrew, Lanark and Dumbarton – focus of key mining, iron and steel, shipbuilding and engineering industries) and 1,400 were examined in the first year. In late 1942 it was extended to cover workers of all ages in the entire Scottish industrial belt and by the end of 1943, 4,126 cases had been dealt with, of which 1,200 were analysed in detail (HMSO, 1943: 8). In addition, ordinary incapacity cases were also referred to the scheme, if they fell into the desired type: uncertain and possibly partly neurotic aetiology. The report noted that many referred workers were suffering from: ‘those conditions of debility and vague ill-health that so severely prejudice wellbeing and working efficiency without necessarily causing complete breakdown and absence from work’ (ibid.).
For Halliday this was an opportunity to put into practice the vision of integrated medical care that he had argued for in 1934, and which highlights his proximity to wider debates about social medicine. He described his emergency hospital work:
Analysis of the first 200 cases showed that 40% were examples of psychoneurosis and another 30% could be allocated to the category of psychosomatic organic disease … steps were taken to supplement medical treatment with socio-medical action [including] instruction on psychosomatic and social medicine to the resident medical staff; institution of a new case record which demanded information concerning patient’s personality and social background; appointment of social worker to interview patient’s relatives; closer co-operation with Labour Exchange … its representatives visited hospital weekly and discussed with physician the disposal of patients … [and] their suitability for particular forms of work. The results of this experiment have been satisfactory, the great majority of patients being able to return to … and … remain at work. (Halliday, n.d.[b]: v)
Halliday felt that such exposure to integrated preventive and clinical medicine had allowed a ‘maturing in experience and outlook’ of ‘my thoughts on the nature and meaning of illness’. It also showed how integrated medicine could work in integrated services (Halliday, n.d.[b]: v).
This mature approach was reflected in new papers, on disabling diseases in miners, on the principles of aetiology and the characteristics of common psychosomatic affections, which, along with articles on psychosomatic medicine written for the DHS’s Health Bulletin (Halliday, 1943a, 1943b, 1946), formed the basis of 1948’s magnum opus, Psychosocial Medicine: A Study of the Sick Society.
2.2 Mature ideas
Halliday located his later ideas within a comprehensive form of social medicine which stressed impacts of cumulative effects of physical and psychological noxia on the individual’s pattern of health in historical time and social space. Halliday’s ‘biological etiology’ argued that living human beings were integrated units and that ‘[i]llness represents a vital reaction or mode of behavior of a person to factors of environment which he meets as he moves through time’ (Halliday, 1948: 26). Illness was thus caused by interactions between particular individuals and their particular environments. He identified psychosomatic affections as arising out of psychosocial disorders in a ‘sick society’ (ibid.: 196). Such ailments, precipitated by emotions, were many and varied: ranging from duodenal and gastric ulcers, through to some essential hypertension and coronary thrombosis, asthma, menstrual disturbances, ‘fibrositis’, neuritis, rheumatoid arthritis, migraine, to some anaemias, many skin diseases, and miner’s nystagmus (ibid.: 46–7).
In a Freudian ‘ontogenetic’ model, Halliday argued that growing individuals face many potential frustrations to self-development in relations with others. Frustrated instincts breed stores of resentment which (especially if built up in the pre-genital phase) predispose individuals to future psychosomatic illness. However, in the meantime, the ‘unliberated energy of frustrated drives’ is diverted into constructing defences: attempts to ‘achieve adaptation both to the disturbed inner feelings and to the external environment in its psychological aspects’ (Halliday, 1948: 236–7). Life-stresses, like unemployment, encountered later may breach these defences and allow the escape of pent-up anxiety, which may manifest itself in physical symptoms in the predisposed individual because of the essential unity of the psyche and soma as an integrated ‘psycho-neuro-endocrine system’. The illness itself can sometimes be interpreted as a new form of defence, created as a flight from the feared object; for the sick unemployed that Halliday dealt with, this could mean work itself.
Seventy years of profound social change had disturbed ‘social equilibrium’, increasing both the potential for early psychological frustrations (given destabilized gender roles and family units) and the sheer number of potentially traumatic socio-economic events (e.g. specialized division of labour, and unemployment). Contemporary society was riddled with ‘psychosocial disorders’ providing an index of the social health of the nation (Halliday, 1948: 176). There were biological/medical disorders: declining fertility, the blending of gender roles, increasing incidence of psychosomatic affections. Second, there were economic and industrial indices: increasing sickness and absenteeism rates, falling output, unemployment and strikes. Third, there were anti-social/criminal indices such as increasing delinquency and suicide rates. Fourth, there were political indices, such as social fragmentation – class war, the re-emergence of regional nationalism – and mass emigration. Fifth, there were loss-of-respect indices, where, for example, discrete social groups (like the unemployed) became acutely vulnerable to infectious disease, or lost the moral will to maintain hygiene and/or appearance adequately. Finally there were cultural indices: the increasing return of the ‘primitive’, sexual and ‘visceral’ in the arts; increasing intellectualism; the decline of ‘vital’ religion, as moral sheet anchor and shared sense of purpose; and a rise in escapism (gambling, football, movies) (ibid.: 177–8).
A more visceral art was accompanied by increases in ‘visceral’ forms of illness – psychoneurotic and psychosomatic affections. Similarly, growth of reflexive intellectualism in art and literature was mirrored in ‘modes of rationalized, automatized, and obsessional existence’, increasingly prevalent during the inter-war years. These modes shaded into the obsession with ‘perfectionist schemes of administrative planning’ and ‘regimentation and control by the state’ which treated the individual as a productive unit, rather than as a human life, and thus ‘inflicted damage upon the vitality, vigour, and enterprise of the group’ (Halliday, 1948: 216). Such psychosocial disorders were both an indication of, and a provocation to, psychosomatic illness, both in this and future generations (ibid.: 176–9) since:
The inner society of the individual is a reflection of his outer society; the symptoms of the problem group are the symptoms of the problem child; and, with special reference to the psychosomatic affections: Failure of the integration of the social group is attended by failure of integration of the psych-neuro-endocrine system of its members. (Halliday, 1948: 149)
Individual health rested on social health; social reintegration could only be achieved when each individual and group understood and could achieve its social purpose, impossible within current social forms (Halliday, 1948: 221). Although vague on ‘social therapeutics’ (ibid.: 152) Halliday had observed during the Second World War the emergence of positive new ‘social patterns’ which promised the new society of healthy social fulfilment. Within this, integrated organization of medical services should reflect a newly epistemologically integrated medicine. The general practitioner – on the front line of disease – should operate in a group practice supported by [i]ts team of social workers, district nurses, clerks and representatives of the Ministry of Labor and Welfare Departments – even of industry’ (ibid.: 205). Medical practice and provision must be integrated to facilitate social reintegration.
However, for Halliday, medical knowledge itself had not escaped disintegrationist tendencies. The application of the method of the natural sciences to medicine (‘mechanismic etiology’: Halliday, 1948: 17) had led to the ‘human organism’ being treated as a machine with mutually adjusted parts working together; illness became mechanical breakdown. Diagnoses were simply labels: functions of this conception, they pointed to faulty parts or localized lesions. Medical action was ‘tinkering with the machine’. A new generation of ‘clinical technicians’ regarded this as true scientific medicine which encapsulated the nature of illness. However it ignored the older physician’s ‘earlier biology known as natural history’ (Halliday, 1948: 20) – grounded in reverent observation. Glasgow medicine’s touchstone for this observational approach was William Gairdner’s The Physician as Naturalist (McNee, 1954; Gairdner, 1889: 4). Halliday reformulated it thus:
The biological viewpoint is concerned primarily not with mechanism … but with the individual and his environment. Illness is regarded not as a fault in the parts but as a reaction, or mode of behavior or vital expression of a living unit as he moves and grows in time. Cause … lies both in the nature of the individual and … of his environment at a particular point in time. (Halliday, 1948: 20)
This included psychological as well as physical environments and aspects of the individual. In the reintegrated medical knowledge (as in its service provision) disease must be seen as a disturbance of the whole person: ‘not so much … a bodily disease as a disturbance of the “life” … if attention is paid early not only to the “lesion” … but also to the person, his life situation, and his way of living, much may be effected in preventing … reoccurrence’ (Halliday, 1948: 238).
3 Halliday, medical holism and medical modernism
Halliday argues at the beginning of Psychosocial Medicine that doctors have forgotten basic, underlying ideas of what causes illness, and suggests that a critical re-examination would reveal fundamental conceptual errors: a focus on specific cause ‘makes us forget the multiplicity or synergy of “causes”‘ (Halliday, 1948: 40). Such thinking has fragmented medical knowledge and practice into specialties which ignore the whole ‘fused flux of person, environment–mechanism–illness’. For Halliday, ‘In reality the individual and his environment interpenetrate and cannot be sundered’ (ibid.: 30, n. 3).
Halliday’s medical epistemology marks him as a contemporary medical modernist and holist: he wants a new ‘integrated’ medicine in which the boundaries of objectivity and subjectivity are collapsed as part of a new view of the relationship between the individual and external reality. Much of Halliday’s discourse of taking medicine away from the laboratory and into the community has strong similarities with the ideas of other contemporary social medicine pioneers, such as John Ryle (Ryle, 1936: 409). However, more tellingly, Halliday’s thoughts are also echoed in the wider currents of contemporary British medical holism from the 1930s (Lawrence, 1985, 1998, 2000). Holists now became particularly visible, defending the primacy of observational method over experimental science in rhetorical battles over the direction and ownership of clinical research. Deflecting science was no longer an option; the question now was accommodating it within theory and practice, while retaining the clinic’s ultimate intellectual authority and professional leadership (Hull, 2007; Lawrence, 1999). However, the debate also reflected the variety of different scientific medicines already practised in large medical centres throughout Britain.
Within this debate, loosely articulated and imprecise ideas of how the body worked as an integrated and harmonious whole were often deployed by elite clinicians to argue for the continued primacy of the observational, empirical clinical method.
However, Halliday’s holism spoke with a strong Glaswegian accent. In Glasgow, inter-war scientific medicine – as with Ivy Mackenzie – entailed a particular, corresponding medical holism; ‘clinician-scientists’ (Nicolson and Smith, 1997: 18) integrated laboratory and clinic but retained primacy for clinicians partly by arguing that patients were unified entities of soma and psyche. Noah Morris, professor of Materia Medica and Therapeutics, spoke about the indivisibility of the patient’s body, mind and environment. The individual was a complex psycho-biostatic system with both interior and exterior environments which interacted constantly; ‘health’ and ‘illness’ measured the organism’s successful adaptation, homeostatic balance and retention of self-integrity (Morris, 1944: 27–8). As Morris argued:
The patient is not merely the addition of circulatory, respiratory and excretory symptoms – a sort of heart-lung-kidney preparation – but a human being with all the desires and emotions, hopes and fears of humanity. Whereas the physiologist and pharmacologist can more or less isolate the object of investigation, the patient, like other living organisms, cannot be disassociated from this environment. One merges with the other with mutual action and interaction. (Morris, 1944: 27–8; emphasis added)
Morris was impressed by surveys indicating the range of variations in both normal and diseased states and commented that ‘Treatment based on the view that a patient is ill because of unemployment or family trouble is often more scientific than that which is founded on the results of a blood test or an x-ray photograph’ (Morris, 1944: 27–8). This contemporaneous Glaswegian holistic and empirical medical philosophy, with its accompanying inclusive cognitive modernist epistemology, and the similarities in the mode of expression, are strikingly resonant of Halliday’s own formulations.
Halliday also shared in the wider Scottish traditions of holistic medical thought exemplified by A. J. Brock, with whom he corresponded about the perversion of government and the horrors of modern society (Brock, 1938a: 762–3; 1938b: 1115; Cantor, 2005). Halliday’s distaste for modern forms of social and artistic life marks him as part of what Dorothy Ross has termed ‘aesthetic modernism’, which ‘turned inward away from the world of democracy, bureaucratic organization, specialized function and industrial capitalism’. Tellingly, Ross argues that this modernist reaction, though usually productive of a rejection of Romanticism and realism in the arts, also included those, from Halliday to Lawrence’s elite holist clinicians, who wished, ‘nostalgically to renew the old’ (Ross, 1994: 8).
Halliday can also be characterized in Ross’s terms as a ‘cognitive’ modernist: like Henry Head (Jacyna, 2008) he disputes the sufficiency of existing definitions of objective ‘science’ and seeks to reintroduce into them more subjective or experiential elements. Halliday rejects the reductionism of ‘biological’ or ‘mechanismic etiology’ for integrated medicine that includes both biological and psychological relations between individual and environment. He now views the mind/body relationship in terms of the essential indivisibility of the individual: mind/body/environment are co-constitutive. The mind/body problem is a mirage created by the position of the observer. Neither organic nor functional approaches alone provide a ‘fundamental etiological basis for the division of illness’:
[T]he mysterious phrase ‘mind and body’ … seems to indicate that an individual is composed of two distinct and contrasted entities – a mind entity and a body entity. If the phrase has any meaning at all it is this: the individual may be studied by a psychological [functional] approach and the individual may be studied by a structural or physical approach. It is our techniques or methods of investigation which are diverse and multiple – not the individual, which is a unity. (Halliday, 1948: 229–30)
Reductionist science must fuse with psychological inputs to save ‘mankind’ from ‘social catastrophe or even destruction’. It was ‘neither sense nor science’ to ignore the spiritual or psychological aspects of life (Halliday, 1948: 223).
Halliday returned to Gairdner’s concept of physician as naturalist by employing a reformed conception of science that collapsed the objective/subjective boundary. Halliday’s was a Romantic science which extended the Enlightenment project’s positivistic science by integrating a new realm of experiential information, preserving intellectual rigour (and thus socio-cultural authority) by manifesting it statistically.
Ross argues that ‘modernism’ was a broad church. It always involved a ‘moral and aesthetic revolt against the existing conditions of cultural-social life’, a rejection of positivism in social thought and philosophy, and the avowal of the subjectivity of perception and cognition that problematized what Hughes termed the ‘disparity between external reality and the internal appreciation of that reality’ (Ross, 1994: 4; Hughes, 1958: 15–16). However, Ross also stresses the heterogeneity of modernism: ‘The cultural constellation identified … as modernism … discloses a number of modernisms with commonalities and differences appropriate to their historical and interpretive context’ (Ross, 1994: 8).
So Halliday’s reformed medicine emerges as a type of modernist, holistic Romantic science of social medicine which retained experimental and quantitative approaches but integrated experiential knowledge. Ross’s argument about the heterogeneity of modernism is thus also applicable to medical holism and social medicine, but here it should be supplemented by my argument, expressed elsewhere, about contemporary scientific medicine(s) (Hull, 2007). There were many, not one (medical holisms, social medicines and scientific medicines); each was shaped by a local medical culture, with its characteristic (evolving) ways of thinking and working.
Conclusion
Halliday’s intellectually and practically integrated psychosocial medicine developed out of Glasgow’s physical and intellectual environment and was mediated by the material administrative processes of NHI and EMS, which allowed him to manifest psychosocial forces and afflictions. The development of Halliday’s thought is thus best explained in the same way that Halliday himself sought to explain illness: as constructed by and contingent upon the interaction of individual and environment.
In the 1930s–1940s, versions of ‘Medical Holism’ and ‘Social Medicine’ emerged partly from debates about relative roles for observational and experiential knowledge in theory and practice. They are a feature of the psychologization of British medical discourse, but are also about contemporary relationships between professional power and varieties of knowledge and practice. Because they are about local as well as national power relationships, they also come in various hybrid types, shaped and mediated by local medical cultures. Anti-reductionists and psychologists shared concerns about increasingly experimental medicine. Thus holism was one entry point for the psychological discourses that permeated medicine in the 20th century. However, patterns of interaction were complex, not one way, and were mediated by local factors to produce many variants of medical holism, of social medicine and of scientific medicine, and sometimes, as in the case of Halliday’s Glaswegian clinical holist version of scientific social medicine, hybrids of all three.