‘‘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.