Book Review
The Cambridge Illustrated History of Medicine
Reviewed by: Dr. Graham Mooney (Centre for Metropolitan History)
When confronted with the term 'Illustrated' in a book title, how many historians, I wonder, would not be tempted to inwardly scoff and mentally store the book on the coffee table of their departmental common room? This review begins with a warning against such sentiments. In the final pages of The Cambridge Illustrated History of Medicine, Geoff Watts discusses the important rise of patient self-help and support groups. He observes that:
'All decisions about health and disease were once regarded by doctors as matters for them alone. Patients had a passive role; having been told what was the matter with them (and sometimes not even that) their only task was to obey whatever instructions the doctor thought fit to issue.' (p. 371)
Introductory texts such as The Cambridge Illustrated History of Medicine — which is but one title in a wide range of historical pictorial primers produced by Cambridge University Press — are perhaps most fruitfully regarded as the practitioners' contributions to historical self-help groups. They deserve to be taken seriously for at least two reasons. First, it behoves all medical historians to ensure that newcomers to the subject — be they potential first-year undergraduates or bypassing lay-readers — are exposed to books that not only stimulate their interest, but also convey the wealth and breadth of the subject matter. This should be done without on the one hand alienating or on the other patronising the reader. Secondly, if written and edited well, such books should be a useful barometer to the current state of the discipline. The purposes of producing (and the criteria for reviewing) such texts consequently differ from those of publishing monographs based upon original research. This makes them no less significant to the process of contributing to the wider body of historical knowledge: indeed, we would do well to bear in mind that The Cambridge Illustrated History of Medicine and books of similar ilk retain the potential to motivate the medical historians of the future. In assessing the success of the volume, this review will thus place emphasis upon the primarily editorial concerns of writing, editing and presenting an illustrated introductory text to a complex and fascinating subject. While this approach somewhat compromises evaluation of written content, in a review of this type one is acutely aware that the right of reply lies with the editor and not with the individual authors. It would be grossly unfair to expect Roy Porter to defend the opinions of the other contributors. Although some of the criticisms will therefore be just as important to the publisher as the editor and the book's potential audience, I have chosen to adopt this approach for Reviews in History because the editorial process for a volume of this genre is surely applicable across all branches of the discipline.
As well as being 'one of the most distinguished and prolific writers and researchers into the history of medicine' (and I see no reason to argue with the book-sleeve here), Roy Porter is also perhaps the most ubiquitous in the popular media. In this respect, then, one expects him to be in a unique position to bring together other medical historians of like stature and to adeptly manipulate the textual and contextual material at his and his colleagues' disposal for a volume intended for a largely non-specialist audience. Professor Porter has certainly succeeded on the first count. I must confess, however, to being a little surprised at the absence of a list of contributors with at least a few biographical details. The reader only has the rather vague dust-jacket blurb as a guarantee that the volume is 'written by a team of world-renowned specialists in medical history'. Renowned to whom? Medical historians? Most definitely. The rest of the population (i.e. the potential readership of this book)? Probably not. This is perhaps a minor quibble, but alert readers surely require and deserve some further assurance of authority than is proffered here. The issue of referencing and bibliographic range falls into a similar realm of criticism. I suggested above that introductory texts should be careful neither to alienate nor to patronise the uninitiated reader. A massive number of references, often pointing the reader in the direction of obscure specialist texts and articles as well as more general works can serve to intimidate, while too few bibliographic notes may not satisfy the desire for closer follow-up reading. A useful method of overcoming this problem is to have detailed notes for the more eclectic works and a separate section listing more general texts. Overall, this volume has got the balance just about right. A 'Further Reading' section for general works, which is divided by chapter headings, largely rescues the uneven number of specialist notes for individual chapters (ranging from 66 references for Edward Shorter's chapter on 'Primary Care' to just two for John Pickstone's 'Medicine, Society and the State').
It would be interesting to learn from Professor Porter — hopefully without breaking too many confidences — how the inclusion and exclusion of such details were mediated between individual authors, the editor of the volume and the representatives of the publisher. The questions of choice and location of illustrations as an accompaniment to the appropriate text is also an important one for this triumvirate of interests. Academics are more than adept at working with tables, graphs and maps — not only as handy visual tools, but more fundamentally as the focal points of their analysis. One of the dilemmas of using other forms of visual representation to complement text (be they paintings, sculptures, cartoons, or even false-colour magnetic resonance images (MRI) as on p. 7) must be how to integrate them in a meaningful way. Without propitious harmonisation between print and picture, the latter may appear to be a needless luxury. On the whole, it must be emphasised that the selection, range and deployment of illustrations in this volume is excellent, but I did have reservations about the unambitious way in which they were accompanied by text in some cases. The illustrations on pp. 130-1 in Edward Shorter's chapter on 'Primary Care' provide us with two contrasting examples. An 1857 painting by Reinhard Zimmermann on p. 130 shows a doctor's smallpox vaccination clinic in Germany. The accompanying text informs us that vaccination replaced inoculation in the nineteenth century and that the vaccination of children subsequently became compulsory in many countries. However, being personally interested in smallpox vaccination, my closer examination of the painting raised some questions that were unanswered in the main text: why were the children vaccinated together and not seen individually by the doctor? (was it because arm-to-arm vaccination was practised?); were the young mothers in the picture also vaccinated? (the need for re-vaccination at puberty and in early adulthood was much debated in the late nineteenth century). I think that by more frequently raising such issues in direct relation to the illustrations, some of the pictures could have been integrated with text much more effectively. This assumes, of course, that the illustration is appropriately placed within the written passages in the first place: that Zimmermann's painting appears amidst Shorter's wonderfully-written section on the development of physical examination is somewhat puzzling. Not so the picture on the facing page, showing a physician (probably Jean-Martin Charcot) conducting a percussion examination (tapping of the ribcage) on a patient, in a ward of what is probably a Parisian teaching hospital. Medical students look on, absorbing Charcot's modern techniques of observation. There can be no doubt that the illustration is well chosen and perfectly placed to accompany and embellish Shorter's narrative. Unfortunately, the reader is not told the date of the painting or even the artist's name (although it must be admitted that oversights of provenance such as this are very rare).
The chapter structure, correctly in my view, adopts a thematic rather than a restrictive chronological order. The former draws upon the strengths of the individual authors and reduces the problem of laboriously linking subject matter between time periods that is inherent in the latter approach. This is not to say that a thematic structure can — or, indeed, should — deal adequately with topics in isolation and very often themes overlap unhelpfully. There were two stark examples of this. First, Porter's chapter title posing the question, 'What is Disease?' actually followed Kiple's contribution on the 'History of Disease' (Kiple's chapter, given the limitations of this type of writing, is a fine sweeping account of global historical epidemiology. He is especially strong on coupling 'big themes' — such as the agricultural revolution and urbanisation — with shifts in the disease panorama). A second instance arose in the way that Shorter's account of the importance of medical science for the 'making of the modern doctor' (pp. 126-32) in his 'Primary Care' chapter actually preceded Porter's chapter on 'Medical Science'.
To point out these issues in fact serves to stress interconnectedness in the development of all aspects of disease and medicine with wider social, political and economic forces. How these factors have shaped the medical landscape that we observe today is properly the paramount task in the writing of medical history. As the opening quote in this review also demonstrates, Western society has become increasingly subjected to a medical model of health. Until comparatively recent times, this has been augmented with a medical model of medical history — the decontextualised deification both of (in)famous medical personae and their achievements or misdeeds. With an appendix containing both an index of medical personalities and a chronology of significant events in medicine, the book does indeed nod its head in the direction of this tradition. The greater body of the text quite rightly defers to it, too, but it also reflects the more recent trends in the social history of medicine by treating medicine as the product of a variety of factors. The importance of war and the military upon the development of medicine is apparent in very contrasting ways. Studies in army hygiene in the eighteenth century were important for an understanding of the relationship between dirt, diseases and overcrowding (Kiple, p. 39). Porter observes how the First World War influenced surgery and helped create a new type of specialist doctor in Britain, thus establishing a pattern that exists to this day (p. 220). Meanwhile, John Pickstone, in his chapter entitled 'Medicine, Society and the State', elects to emphasise that the medical theatres of the Second World War were far more 'scientific' than the trenches of the First. The complicity of German medical academics with the racial doctrines of anti-Semitism aided the legitimisation of mass murder and experiments on prisoners. Pickstone's words remind us of the chilling power of medicine to shape and define a society at any one point in historical time:
Medicine was central to this monstrous [Nazi] politics, because it depends on and so helps define the boundaries of humanity. In the case of Nazi medicine, non-Aryan races were formally defined as subhuman and thereby as expendable.' (p. 333)
The scientific and technical expertise that built up during the Second World War also benefited the development of drug therapy and the pharmaceutical industry, Miles Weatherall commenting upon the significance of chemical warfare research for advances in chemotherapy for cancer (pp. 272-3). Highlighting these examples also draws attention to the military triumphalist language adopted by medicine and its historians that has been so influential in establishing and maintaining the dominance of the Western scientific tradition. (Examples: 'Disease Conquers the New World', p. 30; 'The Battle Against "Inflammation"', p. 125). But they also emphasise the intriguing ways in which the virtually endless relationships between medicine and the wider world can be traced throughout this book. (Thankfully the awareness of these is both characteristic and representative of much of the writing in modern medical history). For example, in his chapter on 'Hospitals and Surgery', Roy Porter traces the pattern of hospital provision in London back to the Age of the Enlightenment (p. 213). The social history of mental illness has proved a highly fruitful area of research in recent years and deservedly merits a chapter in this volume. It is also one topic which remains constantly at the forefront of the public consciousness. Thus, in concluding a brief yet wide-ranging and authoritative survey of the field, Porter draws attention to the paradoxical implementation of under-funded central government policies for the 'resocialisation' of the mentally-ill in Great Britain during the 1980s while Margaret Thatcher, the British Prime Minister at the time, was disclaiming the very existence of a 'society' at all (p. 303).
Given this heartening approach, I was expecting a rather rousing finale in Geoff Watts's chapter, 'Looking to the Future', a few lines of which were quoted at the beginning of this review. Following, as he does, John Pickstone's adroit contribution on 'Medicine, Society and the State', I think that Watts might have chosen to delve more substantially into the possible dynamics of the economic and political imperatives of medicine. Instead we are provided with a checklist to the 'Promise of Medicine' wherein to Pickstone's question, 'Should we allow systems that provide the poor with separate, usually inferior services?' (p. 340) comes the rather fatuous (in my view) response that 'To see medicine's most spectacular achievements you should look to the poor: to the effects of preventive and public health medicine in developing countries' (p. 353). In fact, the subheading 'Benefits to the Poor' appearing in Watts's chapter was yet another opportunity to survey the eventual consequences of such 'achievements' with historical hindsight. The lowering of mortality in developing countries has resulted in the associated problems of population pressure and sustainability. Of the myriad examples charted in this book, this perhaps presents the most astounding instance of the medical impact upon global society. It encapsulates modern Western medicine's dilemma in coming to terms with its own 'success'. If nothing else, The Cambridge Illustrated History of Medicine shows that medical historians have contributed constructively on all fronts to the maintenance of this climate of uncertainty. I, for one, hope that they will continue to do so since it is surely only with an awareness of medicine's own historical fallibility that the currently-emerging big 'achievements' — genetic research, for example — should be allowed to prosper.
October 1996