The detailed essays in this special issue of Medical History provide an opportunity for reflection on common themes as well as on differing medical and historical contexts, specifically examining the organization and practice of European social psychiatry, its various definitions, as well as the history of psychotherapy, in twentieth-century Germany, Holland and Great Britain. The chance has also arisen for one of the two guest editors to comment briefly on various other points that seem pertinent, by way of brief introduction. His fellow guest editor, Harry Oosterhuis, is the author of one essay and co-author of another.

The concept of specific receptors that bind drugs or transmitter substances onto the cell, thereby either initiating biological effects or inhibiting cellular functions, is today a cornerstone of pharmacological research and pharmaceutical development. Yet, while the basic ideas of this concept were first explicitly formulated in 1905 by the Cambridge physiologist John Newport Langley (1852–1925), drug receptors remained hypothetical entities at least until the end of the 1960s. Without doubt, the development of receptor-subtype specific pharmaceuticals—especially the beta-adrenergic receptor antagonist propranolol (introduced in 1965)—promoted the acceptance of the receptor concept in pharmacology. It was only in the 1970s, however, that receptors began to be isolated as specific proteins of the cell membrane and that their composition and conformation began to be explored. During the last twenty years the modern techniques of molecular biology have helped to determine the genetic basis of receptor proteins, to identify their amino acid sequences, and to further elucidate their remarkable structural diversity as well as their similarities and evolutionary relationships. Numerous receptor types and subtypes have since been characterized.

The texts by Paracelsus, Felix Platter and Thomas Willis under consideration here have two things in common, despite their separate historical and cultural settings. First, they describe people who seem to relate both to their own world and to the external world in problematical ways which the authors variously call stultitia, fatuitas or stupiditas: “foolishness”. My translation is intentionally imprecise and will, I hope, restrain the reader from jumping to the conclusion that it signifies any clinical concept recognizable in modern medicine; it is, rather, an algebraic x whose content needs further investigation. The second common factor is that these are precisely the texts which some commentators do indeed believe to contain “early” diagnoses of a modern concept of intellectual disability (“mental retardation”, “learning disability” etc.). This belief, of axiomatic status, presupposes that some such concept has existed across different historical periods in a more or less mutually recognizable form, and therefore that “foolishness”, in the medical writers discussed here, just is, if primitively, our “intellectual disability”. However “foolishness” needs closer examination, which I attempt to provide here.

Food safety is an ever more conflictive issue receiving media attention. “The increased activity of interest groups, the impact of the Common Agricultural Policy and changes in the retail economy have combined to transform [a relatively closed] food policy community into an issue network”. This account of recent changes lacks the historical dimension that might endow it with meaning. It is hardly appropriate to describe the current situation as a reawakening after a long slumber. In France at least, complaints about food safety voiced in numerous newspaper articles echo enduring concerns and a permanent sense of alarm. In 1957, Demain ran a catalogue of food scares: industrial bread causing eczema; wine adulterated with sulphur anhydride (for safe transportation); eggs and milk feared by doctors to be toxic (because chickens were being fed with chemicals or fish, and cattle with ground up rubbish); and filthy conditions on cattle and poultry farms. Much the same sort of list could have been drawn up early in the century during meetings of the Société Scientifique d'Hygiène Alimentaire (created in 1904), or run in the press following passage of the 1905 Food Adulteration Act, or printed in popular pamphlets such as Dr Raffray's Le péril alimentaire (1912). As the Common Market took shape in the 1960s, repeated articles in the daily newspapers relentlessly focused on the issue of food and public health. In France, arguments were continually framed in the language of the 1905 act.

In the early-twentieth century, moves to prevent infection from tuberculosis became an integral part of local government public health schemes. While the scale of action was dependent on individual authorities and ratepayers, interest was not limited to the pulmonary form of the disease. Effort was also directed at tackling bovine tuberculosis, which by the 1890s had become “the most important disease of cows” and, with its zoonotic properties accepted, “a substantial risk to the … consumer”. With meat and milk identified as the main vectors, moves to detect infected livestock and limit the spread of the disease became part of a wider preventive strategy. Measures were introduced to control the sale of tuberculous meat and milk. Eradication schemes were promoted, as concern merged with a growing interest in food safety and agriculture, and became caught up with debates on national efficiency, farming and child health.

The discoveries in the late nineteenth century that malaria is caused by protozoan parasites, which are transmitted by mosquitoes, quickly led to intense speculation about its history in antiquity. The historiography of malaria has passed through three distinct phases during the last hundred years or so. The first generation of historians to consider the effects of malaria did exaggerate its significance in some respects. The argument by W H S Jones that the Greek doctrine of fevers was based on malaria was generally and rightly accepted. However, it is not surprising that his view that malaria was a major reason for the degeneration of the moral character of the ancient Greeks attracted little sympathy. The eradication of malaria from southern Europe in the 1930s and 1940s contributed to a decline of interest in the subject. Subsequently medical historians and even professional malariologists tended to minimize the historical significance of malaria. The revisionist tendencies of this second phase of research led to attempts to reassess some of the details of the evidence upon which Jones had relied. For example, Leonard Bruce-Chwatt and Julian de Zulueta rejected Jones's belief that Plasmodium falciparum, the most dangerous of the four species of human malaria, was already active in Greece in the fifth century BC. They suggested that it started to spread in southern Europe only during the time of the Roman Empire and attributed all the references to intermittent tertian fevers in Hippocratic texts dating to the fifth and fourth centuries BC to the less virulent P. vivax. Although the literature produced during this second phase of scholarship was in many ways more sophisticated, it still suffered from some of the same weaknesses; in particular, analysis proceeded in a purely qualitative manner, without any consideration of the effects of malaria on historical human populations in quantitative terms. A second weakness was a tendency to make generalizations covering the whole of Mediterranean Europe. Since many types of mosquito are incapable of transmitting malaria to humans, mosquito breeding sites do not occur everywhere, and many mosquitoes do not fly further than a few hundred yards from their breeding sites, malaria can only be really understood by micro-analyses, conducted at a very local level, of geography, hydrology, climate, competition between different species of mosquito for breeding sites, and human activities.

The term “social psychiatry” became current in the Netherlands from the late 1920s. Its meaning was imprecise. In a general way, the term referred to psychiatric approaches of mental illness that focused on its social origins and backgrounds. In this broad interpretation social psychiatry was connected to the psycho-hygienic goal of preventing mental disorders, but also to epidemiological research on the distribution of mental illness among the population at large. The treatment called “active therapy”, introduced in Dutch mental asylums in the 1920s and geared towards the social rehabilitation of the mentally ill (especially through work), was also linked with social psychiatry. In a more narrow sense social psychiatry indicated what before the 1960s was usually called “after-care” and “pre-care”: forms of medical and social assistance for patients who had been discharged from the mental asylum or who had not yet been institutionalized. This article focuses on the twentieth-century development of Dutch social psychiatry in this more narrow sense, without, however, losing sight of its wider context: on the one hand institutional psychiatry for the insane and on the other the mental hygiene movement and several outpatient mental health facilities, which targeted a variety of groups with psychosocial and behavioural problems. In fact, the vacillating position of pre- and after-care services was again and again determined by developments in these adjacent psychiatric and mental health care domains. This overview is chronologically divided into three periods: the period between and during the two world wars, when psychiatric pre- and aftercare came into being; the post-Second World War era until 1982, when the Social-Psychiatric Services expanded and professionalized; and the 1980s and 1990s, when they became integrated in community mental health centres.

In the drive for the consolidation of professional authority, physicians in the nineteenth century sought to exert control over all associated occupations, and weaken the influence of competitors. Many historians have chronicled this process, as doctors and their associations sought to proscribe or eliminate competitors such as homeopaths, eclectics, chiropractors and Thomsonians. Others have explored how physicians sought to subjugate allied occupations such as nursing, radiation technology and physical therapy. Such studies consider power struggles in two contexts. First, doctors could and wanted to function without the interference of others in the health industry. Second, doctors sought to enforce a power structure that placed them at the top with all the other health care occupations beneath them, dependent upon the activities of the physicians to maintain their livelihoods. In both contexts, external factors and internal exigencies shaped the future identity of all occupational groups.

The campaigns to prevent smallpox in the eighteenth and nineteenth centuries are commonly understood as the first attempts of large-scale state-sponsored medical intervention in society as such. Before the discovery of the cowpox vaccine inoculation with variolous matter—known as variolation—was the most widespread preventive against the disease. This practice was well established in parts of Asia and introduced to Europe by Mary Wortley Montagu from Constantinople in 1721. While variolation achieved some popularity—particularly in Britain—Edward Jenner's discovery of the cowpox vaccine in 1796 intensified the efforts to combat smallpox, and vaccination was introduced to large parts of the world within a few years. Although the spread of immunization against smallpox is commonly described as highly successful, the campaigns also represented an early encounter between an elitist state-sponsored medicine and various forms of popular resistance.

Hospitals in Germany had traditionally provided care on a voluntary basis. Before the end of the nineteenth century, hospitalization was compulsory only during epidemics or in the case of infectious diseases such as syphilis or leprosy. Voluntary hospitalization normally occurred only when hospital beds were available, when payment was guaranteed, or during emergencies. Towards the end of the nineteenth century, however, there was a definite increase in hospitalization levels, primarily due to two important developments: the introduction of health insurance in 1883, and the growing number and size of hospitals. Health insurance covered its members' hospital expenses, and the hospitals provided facilities for more and more patients.

The early history of psychotherapy in the Netherlands hardly differs from that of the surrounding countries. Somewhat later than in France and Germany, psychotherapy appeared during the last decades of the nineteenth century, with general practitioners who started to treat their patients (mainly for all kinds of somatic complaints) by psychological means. In the early decades of the twentieth century, psychotherapy was narrowed down to mainly psychoanalytic treatment. The patient population consisted of a small élite group of people who belonged to the upper social classes. The practice of psychotherapy was restricted to some “enlightened” psychoanalysts.

The licensing of provincial surgeons and physicians in the post-Restoration period has proved an awkward subject for medical historians. It has divided writers between those who regard the possession of a local licence as a mark of professionalism or proficiency, those who see the existence of diocesan licences as a mark of an essentially unregulated and decentralized trade, and those who discount the distinction of licensing in assessing medical expertise availability in a given region. Such a diversity of interpretations has meant that the very descriptors by which practitioners were known to their contemporaries (and are referred to by historians) have become fragmented and difficult to use without a specific context. As David Harley has pointed out in his study of licensed physicians in the north-west of England, “historians often define eighteenth-century physicians as men with medical degrees, thus ignoring … the many licensed physicians throughout the country”. One could similarly draw attention to the inadequacy of the word “surgeon” to cover licensed and unlicensed practitioners, barber-surgeons, Company members in towns, self-taught practitioners using surgical manuals, and procedural specialists whose work came under the umbrella of surgery, such as bonesetters, midwives and phlebotomists. Although such fragmentation of meaning reflects a diversity of practices carried on under the same occupational descriptors in early modern England, the result is an imprecise historical literature in which the importance of licensing, and especially local licensing, is either ignored as a delimiter or viewed as an inaccurate gauge of medical proficiency.

The link between science, medicine and public trust has been much discussed. Surgery shared in the public confidence in the efficacy of scientific medicine and the good intentions of its practitioners. This does not seem to have been directly linked to evidence of either. Harry Marks has argued that drug manufacturers were not included in the trust accorded to medical practitioners. Regulations and restrictions on the introduction of new drugs in America from the late 1930s were linked to widespread suspicion of commercial motives. The motives of surgeons were not suspected in the same way, and surgery in the 1930s was not subjected to the same tests of safety (or efficacy) that were beginning to be applied to drugs. Surgeons were free to adopt, adapt, or invent any surgical procedure as they saw fit. Was their surgery based on what Marks has called “the vagaries of clinical opinion”, and Christopher Lawrence the “incommunicable knowledge” behind clinical judgment? Or were surgeon citizens of “the republic of science”, basing their practice on what was considered at the time to be acceptable evidence?

In May 1901 an article appeared in the Yarmouth Advertiser and Gazette entitled ‘Alleged Traffic in Pauper Corpses—How the Medical Schools are Supplied—The Shadow of a Scandal’. It recounted that, although a pauper named Frank Hyde aged fifty had died in Yarmouth workhouse on 11 April 1901, his body was missing from the local cemetery. The case caused a public outcry because the workhouse death register stated that Hyde had been “buried by friends” in the parish five days after he had died. An editorial alleged that “the body was sent to Cambridge for dissection” instead and that the workhouse Master's clerk profited 15 shillings from the cadaver's sale. Following continued bad publicity, the visiting committee of Yarmouth Union investigated the allegations. They discovered that between 1880 and 1901 “26 bodies” had been sold for dissection and dismemberment under the terms of the Anatomy Act (1832) to the Cambridge anatomical teaching school situated at Downing College. The Master's clerk staged a false funeral each time a pauper died in his care. He arranged it so that “coffins were buried containing sand or sawdust or other ingredients but the body of the person whose name appeared on the outside [emphasis in original]” of each coffin never reached the grave. This was Hyde's fate too. Like many paupers who died in the care of Poor Law authorities in the nineteenth century, Hyde's friends and relatives lacked resources to fund his funeral expenses. Consequently, he underwent the ignominy of a pauper burial, but not in Yarmouth. His body was conveyed on the Great Eastern railway in a “death-box” to Cambridge anatomical teaching school. Following preservation, which took around four months, the cadaver was dissected and dismembered. It was interred eleven months after death in St Benedict's parish graveyard within Mill Road cemetery, Cambridge, on 8 March 1902. A basic Christian service was conducted by John Lane of the anatomy school before burial in a pauper grave containing a total of six bodies. The plot was unmarked and Frank Hyde disappeared from Poor Law records—the end product of pauperism.

In the first decades of the twentieth century, German-language papers were published which included the term “soziale Psychiatrie” in their titles. At the same time modern concepts of extramural psychiatric care were being developed. Yet, the meaning of “sozial” (“social” in English) varied widely. This was partly due to its ambiguity. “Social” can be used in the sense of small communities or the wider public; it refers to interpersonal relationships, or to relationships between individuals and social groups or other communities. According to this latter meaning, “social” can emphasize the interests of social groups rather than those of the individual. This is how the term was used at the end of the 1920s and during the National Socialist era. On the other hand, “social” may indicate a friendly and humane intention, a philanthropic approach. It was in this sense that the term was widely used in the 1970s when philanthropic psychiatrists and others called for psychiatric reform and the closure or downsizing of asylums for the mentally ill. Moreover, in association with psychiatry, it can mean both the social dimension of mental illness (including the aetiology) that is assumed to lie in human relationships and in social circumstances, and the social and economic effects of mental illness. In parallel with these shifting meanings of the term “social”, the established models of twentieth-century ambulant psychiatric care also showed a variety of structural characteristics.

The revolutionary period in France was a time of great turmoil. It affected all aspects of society including medicine. One feature which has received some attention is the concomitant change in language. The adoption of the general term officier de santé (literally “health officer”) to denote all those practising medicine at the time provides a particularly interesting example, which has never been properly studied. The distinguished French historian of medicine, Jean-Charles Sournia, has said that the term deserves special attention, but he devotes no more than half a page to it.