Kitabı oku: «The Greatest Benefit to Mankind»

CONTENTS

COVER

TITLE PAGE

COPYRIGHT

PRAISE

DEDICATION

I Introduction

II The Roots of Medicine

III Antiquity

IV Medicine and Faith

V The Medieval West

VI Indian Medicine

VII Chinese Medicine

VIII Renaissance

IX The New Science

X Enlightenment

XI Scientific Medicine in the Nineteenth Century

XII Nineteenth-Century Medical Care

XIII Public Medicine

XIV From Pasteur to Penicillin

XV Tropical Medicine, World Diseases

XVI Psychiatry

XVII Medical Research

XVIII Clinical Science

XIX Surgery

XX Medicine, State and Society

XXI Medicine and the People

XXII The Past, The Present and the Future

FURTHER READING

INDEX

ACKNOWLEDGEMENTS

ABOUT THE AUTHOR

ABOUT THE PUBLISHER

CHAPTER I INTRODUCTION

THESE ARE STRANGE TIMES, when we are healthier than ever but more anxious about our health. According to all the standard benchmarks, we’ve never had it so healthy. Longevity in the West continues to rise – a typical British woman can now expect to live to seventy-nine, eight years more than just half a century ago, and over double the life expectation when Queen Victoria came to the throne in 1837. Break the figures down a bit and you find other encouraging signs even in the recent past; in 1950, the UK experienced 26,000 infant deaths; within half a century that had fallen by 80 per cent. Deaths in the UK from infectious diseases nearly halved between 1970 and 1992; between 1971 and 1991 stroke deaths dropped by 40 per cent and coronary heart disease fatalities by 19 per cent – and those are diseases widely perceived to be worsening.

The heartening list goes on and on (15,000 hip replacements in 1978, over double that number in 1993). In myriad ways, medicine continues to advance, new treatments appear, surgery works marvels, and (partly as a result) people live longer. Yet few people today feel confident, either about their personal health or about doctors, healthcare delivery and the medical profession in general. The media bombard us with medical news – breakthroughs in biotechnology and reproductive technology, for instance. But the effect is to raise alarm more than our spirits.

The media specialize in scare-mongering but they also capture a public mood. There is a pervasive sense that our well-being is imperilled by ‘threats’ all around, from the air we breathe to the food in the shops. Why should we now be more agitated about pollution in our lungs than during the awful urban smogs of the 1950s, when tens of thousands died of winter bronchitis? Have we become health freaks or hypochondriacs luxuriating in health anxieties precisely because we are so healthy and long-lived that we now have the leisure to enjoy the luxury of worrying?

These may be questions for a psychologist but, as this book aims to demonstrate, they are also matters of historical inquiry, examining the dialectics of medicine and mentalities. And to understand the dilemmas of our times, such facts and fears need to be put into context of time and place. We are today in the grip of opposing pressures. For one thing, there is the ‘rising-expectations trap’: we have convinced ourselves that we can and should be fitter, more youthful, sexier. In the long run, these are impossibly frustrating goals, because in the long run we’re all dead (though of course some even have expectations of cheating death). Likewise, we are healthier than ever before, yet more distrustful of doctors and the powers of what may broadly be called the ‘medical system’. Such scepticism follows from the fact that medical science seems to be fulfilling the wildest dreams of science fiction: the first cloning of a sheep was recently announced and it will apparently be feasible to clone a human being within a couple of years. In the same week, an English widow was given permission to try to become pregnant with her dead husband’s sperm (but only so long as she did it in Belgium). These are amazing developments. We turn doctors into heroes, yet feel equivocal about them.

Such ambiguities are not new. When in 1858 a statue was erected in the recently built Trafalgar Square to Edward Jenner, the pioneer of smallpox vaccination, protests followed and it was rapidly removed: a country doctor amidst the generals and admirals was thought unseemly (it may seem that those responsible for causing deaths rather than saving lives are worthy of public honour). Even in Greek times opinions about medicine were mixed; the word pharmakos meant both remedy and poison – ‘kill’ and ‘cure’ were apparently indistinguishable. And as Jonathan Swift wryly reflected early in the eighteenth century, ‘Apollo was held the god of physic and sender of diseases. Both were originally the same trade, and still continue.’ That double idea – death and the doctors riding together – has loomed large in history. It is one of the threads we will follow in trying to assess the impact of medicine and responses to it – in trying to assess Samuel Johnson’s accolade to the medical profession: ‘the greatest benefit to mankind.’

‘The art has three factors, the disease, the patient, the physician,’ wrote Hippocrates, the legendary Greek physician who has often been called the father of medicine; and he thus suggested an agenda for history. This book will explore diseases, patients and physicians, and their interrelations, concentrating on some more than others. It is, as its sub-title suggests, a medical history.

My focus could have been on disease and its bearing on human history. We have all been reminded of the devastating effects of pestilence by the AIDS epidemic. In terms of death toll, cultural shock and socio-economic destruction, the full impact of AIDS cannot yet be judged. Other ‘hot viruses’ may be coming into the arena of history which may prove even more calamitous. Historians at large, who until recently tended to chronicle world history in blithe ignorance of or indifference to disease, now recognize the difference made by plague, cholera and other pandemics. Over the last generation, distinguished practitioners have pioneered the study of ‘plagues and peoples’; and I have tried to give due consideration to these epidemiological and demographic matters in the following chapters. But they are not my protagonists, rather the backdrop.

Equally this book might have focused upon everyday health, common health beliefs and routine health care in society at large. The social history of medicine now embraces ‘people’s history’, and one of its most exciting developments has been the attention given to beliefs about the body, its status and stigmas, its race, class and gender representations. The production and reproduction, creation and recreation of images of Self and Other have formed the subject matter of distinguished books. Such historical sociologies or cultural anthropologies – regarding the body as a book to be decoded – reinforce our awareness of the importance, past and present, of familiar beliefs about health and its hazards, about taboo and transgression. When a body becomes a clue to meaning, popular ideas of health and sickness, life and death, must be of central historical importance. I have written, on my own and with others, numerous books exploring lay health cultures in the past, from a ‘bottom-up’, patients’ point of view, and hope soon to publish a further work on the historical significance of the body.

This history, however, is different. It sets the history of medical thinking and medical practice at stage centre. It concentrates on medical ideas about disease, medical teachings about healthy and unhealthy bodies, and medical models of life and death. Seeking to avoid anachronism and judgmentalism, I devote prime attention to those people and professional groups who have been responsible for such beliefs and practices – that is healers understood in a broad sense. This book is principally about what those healers have done, individually and collectively, and the impact of their ideas and actions. While placing developments in a wider context, it surveys medical theory and practices.

This approach may sound old-fashioned, a resurrection of the Whiggish ‘great docs’ history which celebrated the triumphal progress of medicine from ignorance through error to science. But I come not to praise medicine – nor indeed to blame it. I do believe that medicine has played a major and growing role in human societies and for that reason its history needs to be explored so that its place and powers can be understood. I say here, and I will say many times again, that the prominence of medicine has lain only in small measure in its ability to make the sick well. This always was true, and remains so today.

I discuss disease from a global viewpoint; no other perspective makes sense. I also examine medicine the world over. Chapter 2 surveys the emergence of health practices and medical beliefs in some early societies; Chapter 3 discusses the rise of formal, written medicine in the Middle East and Egypt, and in Greece and Rome; Chapter 4 explores Islam; separate chapters discuss Indian and Chinese medicine; Chapter 8 takes in the Americas; Chapter 15 surveys medicine in more recent colonial contexts, and other chapters have discussions of disorders in the Third World, for instance deficiency diseases. The book is thus not narrowly or blindly ethnocentric.

Nevertheless, I devote most attention to what is called ‘western’ medicine, because western medicine has developed in ways which have made it uniquely powerful and led it to become uniquely global. Its ceaseless spread throughout the world owes much, doubtless, to western political and economic domination. But its dominance has increased because it is perceived, by societies and the sick, to ‘work’ uniquely well, at least for many major classes of disorders. (Parenthetically, it can be argued that western political and economic domination owes something to the path-breaking powers of quinine, antibiotics and the like.) To the world historian, western medicine is special. It is conceivable that in a hundred years time traditional Chinese medicine, shamanistic medicine or Ayurvedic medicine will have swept the globe; if that happens, my analysis will look peculiarly dated and daft. But there is no real indication of that happening, while there is every reason to expect the medicine of the future to be an outgrowth of present western medicine – or at least a reaction against it. What began as the medicine of Europe is becoming the medicine of humanity. For that reason its history deserves particular attention.

Western medicine, I argue, has developed radically distinctive approaches to exploring the workings of the human body in sickness and in health. These have changed the ways our culture conceives of the body and of human life. To reduce complex matters to crass terms, most peoples and cultures the world over, throughout history, have construed life (birth and death, sickness and health) primarily in the context of an understanding of the relations of human beings to the wider cosmos: planets, stars, mountains, rivers, spirits and ancestors, gods and demons, the heavens and the underworld, and so forth. Some traditions, notably those reflected in Chinese and Indian learned medicine, while being concerned with the architecture of the cosmos, do not pay great attention to the supernatural. Modern western thinking, however, has become indifferent to all such elements. The West has evolved a culture preoccupied with the self, with the individual and his or her identity, and this quest has come to be equated with (or reduced to) the individual body and the embodied personality, expressed through body language. Hamlet wanted this too solid flesh to melt away. That – except in the context of slimming obsessions – is the last thing modern westerners want to happen to their flesh; they want it to last as long as possible.

Explanations of why and how these modern, secular western attitudes have come about need to take many elements into account. Their roots may be found in the philosophical and religious traditions they have grown out of. They have been stimulated by economic materialism, the preoccupation with worldly goods generated by the devouring, reckless energies of capitalism. But they are also intimately connected with the development of medicine – its promise, project and products.

Whereas most traditional healing systems have sought to understand the relations of the sick person to the wider cosmos and to make readjustments between individual and world, or society and world, the western medical tradition explains sickness principally in terms of the body itself – its own cosmos. Greek medicine dismissed supernatural powers, though not macrocosmic, environmental influences; and from the Renaissance the flourishing anatomical and physiological programmes created a new confidence among researchers that everything that needed to be known could essentially be discovered by probing more deeply and ever more minutely into the flesh, its systems, tissues, cells, its DNA.

This has proved an infinitely productive inquiry, generating first knowledge and then power, including on some occasions the power to conquer disease. The idea of probing into bodies, living and dead (and especially human bodies) with a view to improving medicine is more or less distinctive to the European medical tradition. For reasons technical, cultural, religious and personal, it was not done in China or India, Mesopotamia or pharaonic Egypt. Dissection and dissection-related experimentation were performed only on animals in classical Greece, and rarely. A medicine that seriously and systematically investigated the stuff of bodies came into being thereafter – in Alexandria, then in the work of Galen, then in late medieval Italy. The centrality of anatomy to medicine’s project was proclaimed in the Renaissance and became the foundation stone for the later edifice of scientific medicine: physiological experimentation, pathology, microscopy, biochemistry and all the other later specialisms, to say nothing of invasive surgery.

This was not the only course that medicine could have taken; as is noted below, it was not the course other great world medical systems took, cultivating their own distinct clinical skills, diagnostic arts and therapeutic interventions. Nor did it enjoy universal approval: protests in Britain around 1800 about body-snatching and later antivivisectionist lobbies show how sceptical public opinion remained about the activities of anatomists and physicians, and suspicion has continued to run high. That was the direction, however, which western medicine followed, and, bolstered by science at large, it generated a powerful momentum, largely independent of its efficacy as a rational social approach to good health.

The emergence of this high-tech scientific medicine may be a prime example of what William Blake denounced as ‘single vision’, the kind of myopia which (literally and metaphorically) comes from looking doggedly down a microscope. Single vision has its limitations in explaining the human condition; this is why Coleridge called doctors ‘shallow animals’, who ‘imagine that in the whole system of things there is nothing but Gut and Body’. Hence the ability of medicine to understand and counter pathology has always engendered paradox. Medicine has offered the promise of ‘the greatest benefit to mankind’, but not always on terms palatable to and compatible with cherished ideals. Nor has it always delivered the goods. The particular powers of medicine, and the paradoxes which its rationales generate, are what this book is about.

It may be useful to offer a brief resumé of the main themes of the book, by way of a sketch map for a long journey.

All societies possess medical beliefs: ideas of life and death, disease and cure, and systems of healing. Schematically speaking, the medical history of humanity may be seen as a series of stages. Belief systems the world over have attributed sickness to illwill, to malevolent spirits, sorcery, witchcraft and diabolical or divine intervention. Such ways of thinking still pervade the tribal communities of Africa, the Amazon basin and the Pacific; they were influential in Christian Europe till the ‘age of reason’, and retain a residual shadow presence. Christian Scientists and some other Christian sects continue to view sickness and recovery in providential and supernatural terms; healing shrines like Lourdes remain popular within the Roman Catholic church, and faith-healing retains a mass following among devotees of television evangelists in the United States.

In Europe from Graeco-Roman antiquity onwards, and also among the great Asian civilizations, the medical profession systematically replaced transcendental explanations by positing a natural basis for disease and healing. Among educated lay people and physicians alike, the body became viewed as integral to law-governed cosmic elements and regular processes. Greek medicine emphasized the microcosm/macrocosm relationship, the correlations between the healthy human body and the harmonies of nature. From Hippocrates in the fifth century BC through to Galen in the second century AD, ‘humoral medicine’ stressed the analogies between the four elements of external nature (fire, water, air and earth) and the four humours or bodily fluids (blood, phlegm, choler or yellow bile and black bile), whose balance determined health. The humours found expression in the temperaments and complexions that marked an individual. The task of regimen was to maintain a balanced constitution, and the role of medicine was to restore the balance when disturbed. Parallels to these views appear in the classical Chinese and Indian medical traditions.