Western medical tradition, the authors remind us, is far more than a rigid inheritance that has been passed down from one distinguished medical man to another. Rather, European medicine in the pre-modern age has to be seen in a much wider social, epidemiological and historical context. To appreciate how it has evolved requires a knowledge of institutions, religious and political movements, and the views of individual patients and society on the nature of disease; in short, a picture of health and disease in its broadest cultural setting. The stated aim of the authors (members of the academic unit of the Wellcome Institute for the History of Medicine) is "almost for the first time" to follow this approach in presenting a general account of the history of medicine, and, while doing so, to avoid the all-too-common pitfalls of trying to interpret the past against the yardsticks of current medical knowledge.
As pointed out in Michael Neve's summary to this ambitious undertaking, in most general accounts of the history of western medicine the story is presented in three historical epochs. It starts with the foundation stones, laid down in the classical era and later interpreted and possibly re-invented by Galen. Nothing much then seems to happen until about 1500, after which the remarkable developments in anatomy and physiology of the Renaissance appear out of the wilderness for no apparent reason. Finally, from the late 18th century onwards, with the reformation of medical education, the development of bacteriology and radiology and the rise of the clinical laboratory, the story moves closer to something recognisable as present-day medicine.
While, in this new account, each of these periods up to the 18th century is covered, in some cases quite brilliantly, the continuity of the development of western medicine is restored by an equally good description of the slow improvements in health consequent on fundamental social and political changes during late antiquity and the early Middle Ages, aided by a clear picture of the complex relationship of Islamic medicine to the western tradition during this period. Throughout, the contributions of the "great names" are not underplayed, even though their achievements are analysed in their historical context, and hence much more critically than is often the case in general accounts of medical history.
As the story of the extraordinarily complex interplay between sickness and society that underlies the western medical tradition unfolds, it is interesting to reflect on the roles of professional healers and of "scientific medicine" in the overall picture. For many centuries, and, some would argue, even today, they appear to be marginalised, busily developing, maintaining and ensuring the survival of their institutions and activities from generation to generation, yet playing a relatively small part in determining the overall health of society. Rather, better nutrition, sanitation and control of the environment in general, combined with political measures leading to quarantine, restrictions on travel, and movement of peoples from areas of infection, together with completely unexplained changes in the virulence of individual infectious diseases, have been the prime causes of the gradual improvement in the health of western countries. In the concluding section, the more extreme models of this kind of social evolution - for example those of Thomas McKeown (not mentioned by name but unmistakable in content) - are presented, which suggest that developments in medical practice and in the biomedical sciences over the centuries have had virtually no effect on the well-being of society.
It will be fascinating to see how the authors assess the role of the medical sciences when they come to describe western medical tradition in the 19th and 20th centuries. It is to be hoped that they will take a more balanced view than McKeown and others. For example, to equate the health of society entirely with mortality or frequency data for infectious disease tells us little about the morbidity and chronic suffering caused by the aftermaths of childhood infections such as meningitis and poliomyelitis, or of the misery of tuberculosis and its management in the early part of this century. Even if the frequency of these diseases had continued to decline due to improvements in social conditions, and we will never know whether this would have happened, the accumulated aftermath of pathology in the survivors alone would have continued to cause widespread suffering. The change in the pattern of illness in the second half of this century in western societies due to a scientific attack on infectious disease should not be underestimated.
It must be left to professional historians to assess this exciting new book as a work of medical history, but for those who are involved in the day-to-day provision of health care it has some extremely relevant stories to tell. While the medical profession and the medical sciences are now having a greater impact on the health of society, there is no doubt that any further improvement to our well-being will continue to rest on much broader social issues, particularly in developing countries.
At present the dichotomy is as wide as it ever was between the medical establishment, particularly as reflected by the teaching in medical schools, and the health needs of society as envisaged by government. There are increasing ambitions on the part of the government to have more input in designing the medical curriculum, with the notion of producing the kinds of doctors that will be of "genuine use" to society. And the biomedical sciences, also seen by many as increasingly irrelevant, are coming under attack.
Despite the undoubted successes of western medicine, and medical science, over the past 150 years, its place within overall medical care is still marginal at best and its future precarious. It is to be hoped that the lessons of the great era of the partial conquest of infectious disease are not forgotten. As evidenced by the history of western medicine, the tensions caused by the need to move quickly to control disease by social engineering, compared with taking the longer term approach of trying to understand its nature, are certainly not new. There is a danger that the latter, of such importance as the diseases of the West become increasingly complex, will be neglected in our haste for quick answers to current health problems.
Another important message from this survey is that patients' views of the cause and nature of their illnesses have throughout history been of paramount importance in shaping the development of medical care. In this context the authors have put what is now called "complementary medicine" and even "quackery" in their true social setting, an approach today's doctors could well try to emulate, particularly when more Americans now visit a practitioner of complementary medicine before consulting a "conventional" doctor. The gulf between western medical practice and the requirements of modern societies is being increasingly recognised. Many of these tensions become easier to understand when viewed in their historical setting, insights that are vital if today's doctors are to appreciate the aspirations of their patients.
This excellent book paints a picture of the history of medicine as a vital and complex interaction between sick people, society and, to a lesser degree, doctors. In doing so it makes an excellent case for the subject being an integral part of modern medical education and for its relevance to many of the pressing medical issues of today. I hope this beautifully written and illustrated work is read widely and appreciated for what it is - a genuine contribution to our understanding of the complexities and difficulties of the provision of health care in the 20th and 21st centuries. It is a major tribute to the Wellcome Unit and to the work of the Wellcome Trust in maintaining and developing this discipline.
Sir David Weatherall is regius professor of medicine, University of Oxford.
The Western Medical Tradition 800 BC to 1800 AD
Author - Lawrence I. Conrad, Michael Neve, Vivian Nutton, Roy Porter and Andrew Wear
ISBN - 0 521 38135 5 and 47564 3
Publisher - Cambridge University Press
Price - £60.00 and £24.95
Pages - 556