Reviewed by Robin Ganev (Department of History, University of Regina)
Published on H-Histsex (June, 2007)
The Rise of Modern Medicine in the Western World
The exploits of doctors prior to the modern age often make for painful reading. As Edward Shorter explains in his essay "Primary Care," chapter 5 of the recently reissued Cambridge History of Medicine, practices like bloodletting were widespread well into the Victorian period and were prescribed for a broad variety of complaints (p. 108). It is easy to dismiss such practices as not only useless but harmful. As the highly respected American physician Lewis Thomas has pointed out, the history of medicine can often seem "unbelievably deplorable" (p. 8). Not so fast, says Roy Porter in his introduction to the volume. Studying medicine historically can tell us much about how past societies understood the physical world and the functioning of the human body. Porter provides a useful definition of the goals of the historian of medicine: "a historical understanding of medicine is far more than a cavalcade of triumphs. It involves the attempt to explain the more distant and indirect antecedents of modern changes, to show why one path was taken and not another, to examine the interconnections of theoretical and practical aspects of medicine, science, and healing, and doctor and patient; to analyze the relations between the broad trends and leading individuals; and, not least, to lay bare the thinking--often to our minds bizarre and unscientific--that lay behind the physiological and therapeutic systems of the past" (p. 4). These aims are in large part fulfilled by the book.
While paying some attention to other cultures, particularly those that were influenced by the Greek tradition (Byzantium and the Muslim world), the book focuses on the rise of modern medicine in the West. The introduction lists some of the important developments and discoveries deemed worthy of study: the discovery of penicillin, the development of drugs for mental illness, the rise of immunology and cardiology, surgery and organ transplantation, the birth control pill (pp. 2-3). Methods and practices that were not scientifically sound are named but not discussed at length. No doubt this was done for reasons of space. The history of medicine is a huge field, and some kind of focus was necessary to keep this textbook reasonably short. Still, the lack of discussion of non-Western and non-scientific systems of medicine is somewhat disappointing. After all, science was not central to most people's understanding of their bodies until recently, and alternative ways of understanding illness can tell us more about past cultures than modern science.
Porter and the other authors of the volume try to present a balanced view of modern medicine, pointing to both its achievements, such as the triumph over contagious diseases, and its problems, such as its overwhelming cost. There is much in this book that is interesting and worth learning about. Of particular value is chapter 3, on the cultural perceptions of illness, and the final chapter on the problems and achievements of modern medicine.
Porter begins chapter 3 with the concepts of sickness in traditional societies and the connection between the doctor of the body and the doctor of the soul (the priest) (p. 73). Medieval Europe was similar to these oral cultures as pain was understood as holy and sent by God as a trial. Within the ascetic tradition pain was even seen as a blessing, a way to mortify and discipline the flesh, which is why some monks and nuns prayed for illness. This is also the chapter that allows a significant amount of room for discussing systems of medicine other than the scientific one. It describes the humoral system, which came under criticism in the seventeenth century. Porter also points out the persistence of irrational attitudes toward illness despite the rise of modern medicine. In the nineteenth century tuberculosis was eroticized and feverish young women afflicted with the disease were seen as unusually passionate and romantic. In our own time notions of purity and pollution are still attached to illness. An intriguing theme is also psychosomatic illness, described in a subsection called "The Sick Role." Porter explains that a person might perform illness in order to be excused from certain social obligations. This performance is often unconscious. Chapter 3 is a fine chapter, exemplifying the kind of writing Roy Porter is known for and it is a pleasure to read.
The second great strength of the book is its discussion of the problems faced by modern medicine. This is discussed in the introduction, then on and off in various chapters, and finally very competently and engagingly by Geoff Watts in chapter 10 and the addendum. The authors tend to overstate the problems of modern medicine, referring to a backlash, a crisis, and a flight to alternative or "complementary" medicine, but citing few authorities other than Ivan Illich, who wrote in the 1970s and tended to exaggerate the extent to which modern medicine had invaded the lives of individuals. However, this is an important question and the sections dealing with it are some of the most interesting sections in the book. Controlling the costs of health care is certainly still a major issue facing the developing world and few solutions seem to have been found. In the 1990s the state of Oregon developed a system of consulting public opinion on what should be priorities for government funding and compiled a list of 700 treatments, organized according to the importance the public attached to each. After working out the budget the government found it could fund treatments up to number 587 (p. 315). But as Watts points out in the addendum, no other governments have adopted this approach, perhaps because it seems coldly calculating and leaves out important treatments like drugs for the advanced stages of HIV disease. Watts also discusses modern people's obsession with their health, which in a way adds to the cost. Visits to the doctor are more common than ever before, as more and more conditions are medicalized. Our concern about our health can sometimes find bizarre expressions. For instance, the Japanese have built an "intelligent toilet," which analyzes people's urine and feces and sends the results to a computer. If a problem is found, the person is contacted and told to go to the doctor.
A third problem faced by modern medicine is overpopulation in the Third World. Watts argues that overpopulation can partly be blamed on medical advances, especially the eradication of many contagious diseases. The benefits of saving lives through drugs are offset by the economic problems faced by developing countries. Maurice King, who has worked for years in Africa, has said that sometimes it is better to let sick infants die of disease than to save their lives only to let them die of starvation later. As Watts recognizes in the addendum, it seems that this argument overstates the extent to which diseases have been conquered in the Third World. HIV is a contagious disease, and its rates are higher in Africa than anywhere else. Also, underprivileged countries have poor access to drugs and health care. The causes of overpopulation are numerous, and it seems unfair to say modern medicine is at fault, when we enjoy so much more of it in the West than do the people of the Third World.
Despite the presence of several excellent chapters, the book is not flawless. Some of the writing tends to be plodding and difficult. Chapter 5, for example, lists the names of practitioners, their careers and discoveries, in an excruciatingly dry and factual manner. While this makes for a good reference tool, such an approach is more suited to a dictionary than a textbook. A textbook should be a lot more engaging and accessible if it is to convey a sense of excitement about the subject matter to beginners.
The organization of the chapters can sometimes seem arbitrary. For instance, chapter 5 is called "Medical Science" but within it is a subsection called "Medicine Becomes Scientific," which seems redundant, especially since the rest of the chapter is also about how medicine became a science. The introduction to chapter 6 says that hospitals and surgery are inseparable but the rest of chapter shows this was not so until the twentieth century. Yet the bulk of the chapter deals with the history of surgery and hospitals prior to 1900. Thus the decision to lump these two topics together appears poorly justified.
The thematic organization of the book was perhaps conceived as a way of breaking with the predictability of the more traditional chronological approach. This can cause a lot of repetition. For example, several chapters talk about Ivan Illich's critique of modern medicine. Repeatedly we are told of the role of Christianity in the creation of the institution of the hospital. Perhaps if we endorse the old maxim that "repetition is the key to learning" and bear in mind that this was written for students, this feature may be seen in a positive light.
Another problem with the book is terms and definitions. It would benefit from a more careful terminology, a clearer distinction between different concepts. For instance, in chapter 2 we are told there is a distinction between healing and medicine, because unlike the former the latter is a body of knowledge to be learned (p. 47). Clearly this is an imperfect distinction, as most healers rely on some kind of knowledge they have learned, even if it be the knowledge of spirits and how they can afflict the human body. Also, most students of medicine are interested in how it can be used to heal. Chapter 3 is different from chapter 1, says Porter, because chapter 1 deals with disease but chapter 3 deals with illness. Disease is the biological phenomenon while illness is the feeling of being sick. Disease is objective, illness subjective (p. 72). This would be more effective if the chapter were not called "What is Disease?" which makes the reader think that it is, in fact, the same as chapter 1, named "The History of Disease." The term "imperialism" is also used rather loosely and in chapter 8 it is really not clear why one of the subsections is called "Imperialism and Social Welfare" when its focus is the rise of socialized medicine in the West as a response to perceptions of a socialist threat (p. 278).
A significant omission is a discussion of gender. There is a large historiography on this topic and the book pays some attention to it, but not enough. The chapter on mental illness mentions the medicalization of natural female bodily functions by early psychiatry and medicine. The discussion of the rise of socialized medicine in Britain in chapter 9 talks about how it collaborated with friendly societies and focused on working men but not women. These are interesting issues and require more extensive discussion. A chapter on gender might have helped, and this is something a new textbook on the history of medicine could include.
This brings us to the question of whether it was worth reissuing The Cambridge History of Medicine ten years later. In a way, the answer is yes. Professors are always in search of textbooks. Removing the illustrations and creating a small, light paperback reduces the cost, allowing financially challenged students to purchase the book. On the other hand, the illustrations in the 1996 volume were excellent. They were in color and came with fairly detailed captions, thus adding another dimension to what is often very challenging material. Students readily relate to visual material and this made the 1996 textbook more attractive. Also, the 1996 volume had little vignettes that focused on a particular topic, like bloodletting and the Hippocratic Oath. Thus it contained more information and part of it at least was presented in more accessible form. Finally, the history of medicine is a popular field that grows very quickly, so a new textbook, taking into account more recent work, might in some ways have been preferable to reissuing this volume. Some (but not all) parts of the bibliography under "Further Reading" have been updated and Geoffrey Watts has added a ten-page addendum which is an interesting extension of chapter 10. Still, an entirely new textbook might have been even better.
If there is additional discussion of this review, you may access it through the network, at: https://networks.h-net.org/h-histsex.
Robin Ganev. Review of Porter, Roy, ed., The Cambridge History of Medicine.
H-Histsex, H-Net Reviews.
Copyright © 2007 by H-Net, all rights reserved. H-Net permits the redistribution and reprinting of this work for nonprofit, educational purposes, with full and accurate attribution to the author, web location, date of publication, originating list, and H-Net: Humanities & Social Sciences Online. For any other proposed use, contact the Reviews editorial staff at email@example.com.