Preface

11 May

Preface

‘‘Health is a state of complete physical, mental and social well-being, and  not  merely the  absence  of disease or  infirmity.’’ (The  World Health  Organization)

My primary  purpose  in writing and revising this book has been to pro- vide an updated  introduction to the history  of medicine. Although  the text began  as a ‘‘teaching assistant’’ for my own one-semester  survey course, I hope that  this new edition will also be of interest to a general audience,  and to teachers who are trying to add historical  materials  to their science courses or science to their history  courses. As in the pre- vious edition of this book, I have tried to call attention to major themes in the history of medicine, the evolution  of theories and methodologies, and  the diverse attitudes  and  assumptions  with which physicians  and patients  have understood health,  disease, and healing.

Many changes have taken place in the history of medicine since the

1940s, when Henry E. Sigerist (1891–1957) called for a new direction in the field, a move away from the study of the great physicians and their texts towards  a new concept  of medical history  as social and  cultural history.  From  an  almost  exclusive focus on  the  evolution  of modern medical theories, scholars turned to new questions about  the social, cul- tural, economical, and political context in which healers and patients are embedded. Profoundly influenced by concepts and techniques borrowed from  sociology,  psychology,  anthropology, and  demography, the new social and  cultural  historians  of medicine emphasized  factors  such as race, class, and  gender,  as well as institutional and  professional  affili- ations.  Some arguments  about  the nature  of the field remain, but there is general agreement  that  medical history  is not  simply an account  of the path  from past darkness  to modern  scientific enlightenment.

Given the vitality and diversity of the field today, finding a satisfac- tory  way to present  an introductory survey of the history  of medicine has become increasingly difficult. Thus, a selective approach, based on a consideration of the needs and interests of readers who are first approach- ing the  field, seems appropriate. I have,  therefore,  selected particular examples of theories,  diseases, professions,  healers, and  scientists, and

attempted to  allow them  to  illuminate  themes  that  raise fundamental questions  about  health,  disease, and  history.  The book  is arranged  in a roughly  chronological,  but  largely thematic  manner.

Medical concepts and practices can provide a sensitive probe of the

intimate network of interactions in a society, as well as traces of the intro- duction, diffusion, and transformation of novel or foreign ideas and tech- niques. Medical problems concern the most fundamental and revealing aspects of any society—health  and  disease, wealth  and  poverty,  birth, aging, disability, suffering, and death. All people, in every period of his- tory,  have dealt  with childbirth,  disease, traumatic injuries,  and  pain. Thus, the measures developed to heal mind and body provide a valuable focus for examining different cultures and contexts. Perhaps  immersion in the history of medicine can provide a feeling of kinship with patients and practitioners past and present, a sense of humility with respect to dis- ease and nature, and a critical approach to our present medical problems.

The history  of medicine can throw  light on changing  patterns  of health and disease, as well as questions of medical practice, professional- ization,  institutions, educations,  medical costs, diagnostics,  and  thera- peutics. Since the end of the nineteenth  century, the biomedical sciences have flourished by following what might be called the ‘‘gospel of specific etiology’’—that is, the concept that if we understand the causative agent of a disease, or the specific molecular events of the pathological  process, we can totally understand and control the disease. This view fails to take into  account  the complex social, ethical,  economical,  and  geopolitical aspects of disease in a world drawn closer together  by modern  commu- nications  and transportation, while simultaneously being torn  apart  by vast and growing differences between wealth and poverty.

Public debates about  medicine today rarely seem to address funda-

mental issues of the art and science of medicine; instead,  the questions most insistently examined concern health care costs, availability, access, equity, and liability. Comparisons among the medical systems of many different  nations  suggest that  despite  differences in form,  philosophy, organization, and goals, all have experienced tensions  caused by rising costs and expectations and pressure on limited or scarce resources. Gov- ernment officials, policy analysts, and health care professionals have increasingly  focused their energy and attention on the management of cost  containment measures.  Rarely  is an  attempt   made  to  question the  entire  enterprise  in  terms  of  the  issues raised  by  demographers, epidemiologists, and historians  as to the relative value of modern medi- cine and  more  broadly  based  environmental and  behavioral  reforms that  might significantly affect patterns  of morbidity  and mortality.

Skeptics have said that we seem to exchange the pestilences of one generation  for the plagues of another.  At least in the wealthier, indus- trialized  parts  of the world,  the prevailing  disease pattern has shifted from  one in which the major  killers were infectious  diseases to one in

which chronic  and  degenerative  diseases predominate, associated  with a demographic shift from  an era of high infant  mortality  to one with increased  life expectancy  at  birth  and  an  aging  population. Since the end of the nineteenth century, we have seen a remarkable transition from a period where prevention  was expensive (e.g., installation of sewer sys- tems) and therapy was basically inexpensive (e.g., bleeding and purging) to one where therapy  is expensive (e.g., coronary  by-pass  operations) and prevention  is inexpensive (e.g., exercise and low-cholesterol  diets). The demand for high cost diagnostic and therapeutic technologies seems insatiable,  but it may well be that improvements  in health and the over- all quality of life are better  served by a new commitment to social ser- vices and  community  health  rather  than  more  sophisticated scanners and specialized surgeons. After years of celebrating the obvious achieve- ments  of biomedical  science, as exemplified  by such  contributions  as vaccines, anesthesia,  insulin, organ  transplantation, and  the hope  that infectious epidemic diseases would follow smallpox into oblivion,  deep and disturbing questions are being raised about the discrepancy between the costs of modern  medicine and the role that  medicine has played in terms  of  historical  and  global  patterns   of  morbidity   and  mortality. Careful analysis of the role of medicine and that  of social and environ- mental  factors  in determining  the  health  of the  people  indicates  that medical technology  is not a panacea  for either epidemic and acute dis- ease, or endemic and chronic disease.

A general survey of the history  of medicine reinforces  the funda-

mental  principle that  medicine alone has never been the answer to the ills of the individual  or the ills of society, but human  beings have never stopped  looking to the healing arts to provide a focus for cures, conso- lation,  amelioration, relief, and rehabilitation. Perhaps  a better  under- standing  of previous concepts of health,  healing, and disease will make it possible to recognize the sources of contemporary problems  and the inherent  limitations  and liabilities of current  paradigms.

Once again I would like to express my deep appreciation to John Parascandola and Ann Carmichael for their invaluable advice, criticism, and  encouragement during  the preparation of the first edition  of this book.  Of  course,  all  remaining  errors  of  omission  and  commission remain my own. Many thanks also to the students who took my courses, read my books, and let me know what was clear and what was obscure. I would also like to thank  the History  of Medicine  Division, National Library  of Medicine,  for providing  the illustrations  used in this book and the World Health  Organization for the photograph of the last case of smallpox  in the Indian  subcontinent. I would like to thank  Marcel Dekker,  Inc. for inviting me to prepare  a second edition  of A History of Medicine.

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