The two videos contrast views of health

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The two videos contrast views of health, also discussed by Porter. Can these views be reconciled? Or does this mean that increasing economic inequality will degrade the medical advances of the last centuries?

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Porter, The Greatest Benefit to Mankind, pages 597-718

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http://www.ted.com/talks/richard_wilkinson.html

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Renaissance anatomical illustrations often followed artistic conventions (situating the skeleton in a lifelike pose in a landscape) and played wittily on the tensions between life and death. The contemplation of the skull prefigures Hamlet’s later meditation. Line drawing, Valverde de Hamusco, Historia de la composicion del cuerco humano (Rome: A. Salamanca & A. Lafreri, 1556). TO Mikuláš Teich, true friend and scholar Sick – Sick – Sick. . . O Sick – Sick – Spew DAVID GARRICK, in a letter I’m sick of gruel, and the dietetics, I’m sick of pills, and sicker of emetics, I’m sick of pulses, tardiness or quickness, I’m sick of blood, its thinness or its thickness, – In short, within a word, I’m sick of sickness! THOMAS HOOD, ‘Fragment’, c. 1844 They are shallow animals, having always employed their minds about Body and Gut, they imagine that in the whole system of things there is nothing but Gut and Body. SAMUEL TAYLOR COLERIDGE, on doctors (1796) CONTENTS LIST OF FIGURES LIST OF ILLUSTRATIONS ACKNOWLEDGEMENTS I II Introduction The Roots of Medicine III Antiquity IV Medicine and Faith V The Medieval West VI VII VIII IX X XI XII Indian Medicine Chinese Medicine Renaissance The New Science Enlightenment Scientific Medicine in the Nineteenth Century Nineteenth-Century Medical Care XIII Public Medicine XIV From Pasteur to Penicillin XV XVI XVII XVIII XIX XX XXI XXII Tropical Medicine, World Diseases Psychiatry Medical Research Clinical Science Surgery Medicine, State and Society Medicine and the People The Past, the Present and the Future FURTHER READING INDEX More praise for: The Greatest Benefit to Mankind FIGURES The main organs of the body The four humours and the four elements The heart and circulation, as understood by Harvey Neurones and synapses, as understood by neurologists c. 1900 ILLUSTRATIONS Imhotep. Portrait of Hippocrates. Portrait of Galen by Georg Paul Busch. Portrait of Hildegard of Bingen by W. Marshall. Portrait of Moses Maimonides by M. Gur-Aryeh. The Wound Man, from Feldtbuch der Wundartzney by H. von Gersdorf. The common willow, from The Herball, or General Historie of Plantes by J. Gerard. St Cosmas and St Damian performing the miracle of the black leg by Alonso de Sedano. A medieval Persian anatomical drawing. A medieval European anatomy, from Margarita Philosophica by Gregorius Reisch. A Chinese acupuncture chart. ‘Two Surgeons Amputating the Leg and Arm of the Same Patient’ by ZS. The frontispiece to Vesalius’s De humani corporis fabrica. A medicine man or shaman. An Indian doctor taking the pulse of a patient. Portrait of Vesalius. Portrait of William Harvey by J. Hall. Portrait of Louise Bourgeois. Portrait of William Hunter by J. Thomas. Portrait of Benjamin Rush by R. W. Dodson. An early seventeenth-century dissection. Scenes from the plague in Rome of 1656. A mother and baby, from Anatomia uteri humani gravidi by William Hunter. Three stages of dissection. Opthamology instruments, eye growths, a cateract operation and other eye defects by R. Parr. The preserved skull of a woman who had been suffering from syphilis. Punch Cures the Gout, the Colic, and the Tisick by James Gillray. Breathing a vein by J. Sneyd. An Apothecary with a Pestle and Mortar to Make up a Prescription by A. Park. The interior of a pharmaceutical laboratory with people at work. Philadelphia College of Pharmacy and Science. Portrait of René Théophile Hyacyinthe Laennec Portrait of Louis Pasteur by E. Pirou. Portrait of William Gorgas. Portrait of Joseph Lister. Christiaan Barnard, photographed by B. Govender. Mentally ill patients in the garden of an asylum by K. H. Merz. Sigmund Freud, Carl Gustav Jung, Ernest Jones, Sandor Ferenczi, Abraham Bill and G. Stanley Hall. A male smallpox patient in sickness and in health. A Fijian man with elephantiasis of the left leg and scrotum. An Allegory of Malaria by Maurice Dudevant. A white doctor vaccinating African girls all wearing European clothes at a mission station by Meisenbach. Portrait of Florence Nightingale. A Nurse Checking on a Playful Child by J. E. Sutcliffe. ‘A district health centre where crowds of local children are being vaccinated’ by E. Buckman. Franklin D. Roosevelt. The Hôtel Dieu. Lister and his assistants in the Victoria Ward. A British hospital ward in the 1990s photographed by Emma Taylor. The bones of a hand, with a ring on one finger, viewed through X-ray. Tomographic scan of a brain in a skull. ACKNOWLEDGEMENTS will be heartily tired of hearing their praises sung yet again. As always, Frieda Houser has been a marvellous secretary, keeping everything on the road while I was deep in this book; Caroline Overy an infallible research assistant; Sheila Lawler and Jan Pinkerton indefatigable on the word-processor, and Andy Foley a wiz on the xerox machine. I have been so lucky having their help and friendship for so long. Thanks! New to me have been the help and friendship I have received from Fontana Press. The series of which this book forms a part was first planned ten years ago, and since then Stuart Proffitt, Philip Gwyn Jones and Toby Mundy have been ever supportive, skilled equally in the use of sticks and carrots. Biddy Martin’s copy editing uncovered ghastly errors and eliminated stylistic horrors, and Drusella Calvert compiled a truly thorough index. Friends old and new have read this book at various stages and shared their thoughts, knowledge and criticisms with me. My thanks to Michael Neve, who always reads my manuscripts, and to Bill Bynum and Tilli Tansey for being patient with one who lacks a sound medico-scientific education; and to Hannah Augstein, Cristina Alvarez, Natsu Hattori, Paul Lerner, Eileen Magnello, Diana Manuel, Chandak Sengoopta, Sonu Shamdasani and Cassie Watson, all of whom have read the text, saved me from constellations of errors, shared insights and information, levelled cogent criticisms and helped to keep me going at the moments when all seemed sisyphean. Catherine Draycott and William Schupbach have been immensely helpful with the illustrations. My aim first and foremost is to tell a story that is clear, interesting and informative to students and general readers alike. My thanks to all who have helped the book in that THE USUAL SUSPECTS direction. I also wish to thank all the medical historians and other scholars whose papers I have heard, whose books I have read, and whose company I have shared over the last twenty years. I have the deepest admiration for the expertise and the historical vision of scholars in this field. Panning from Stone Age to New Age, from Galen to Gallo, I cannot pretend personal knowledge on more than a few frames of the times and topics covered. As will be plain to see, I am everywhere profoundly dependent on the work of others. It would simply be distracting in a work like this to acknowledge all such debts one after another in thickets of footnotes. The Further Reading must serve not just by way of recommendation for what to read next but as a collective thank-you to all upon whose work I have freely and gratefully drawn. I have written this book because when my students and people at large have asked me to recommend an up-to-date and readable single-volume history of medicine, I have felt at a loss to know what to suggest. Rather than bemoaning this fact, I thought I should have a shot at filling the gap. Writing it has made it clear why so few have attempted this foolhardy task. The author is grateful to the following for permission to reproduce extracts: from The Illustrated History of Surgery by Knut Haeger, courtesy of Harold Starke Publishers; from A History of Medicine by Jean Starobinski, courtesy of Prentice Hall; from Hippocrates I-IV and The Complete Letters of Sigmund Freud to Wilhelm Fleiss, 1887–1904, edited by Jeffrey Masson, courtesy of Harvard University Press; from The Odes of Pindar, edited and translated by Richmond Lattimore, courtesy of Chicago University Press; from Medicine Out of Control: The Anatomy of Malignant Technology by Richard Taylor, courtesy of Sun Books; from A History of Syphilis by Claude Quétel, courtesy of Blackwell Publishers; from Doctor Dock: Teaching and Learning Medicine at the Turn of the Century by Horace W. Davenport, courtesy of Rutgers University Press; from Steven Sondheim’s West Side Story , copyright 1956, 1959 by the Estate of Leonard Bernstein Music Publishing Company UC, Publisher; Boosey & Hawkes Inc., Sole Agent. International Copyright secured. All rights reserved; from The Horse Buggy and Doctor by A. E. Hertzler, courtesy of the Hertzler Research Foundation; from Inequalities in Health: The Black Report, crown copyright, reproduced with permission of the Controller of Her Majesty’s Stationary Office: from the British Medical Journal (1876), courtesy of the BMJ Publishing Group; from The Doctor’s Job by Carl Binger © 1945 by W. W. Norton & Co. Inc., renewed © 1972 by Carl Binger. Reprinted by permission of W. W. Norton & Co. Inc.; from Women’s Secrets: A Translation of PseudoAlbertus Magnus’s ‘De secretis mulierum’ by Helen Rodnite Lemay, courtesy of the State University of New York Press © 1992; from Diary of a Medical Nobody by Kenneth Lane, courtesy of Peters, Fraser and Dunlop; from Sketch for a Historical Picture of the Progress of the Human Mind translated by June Barra-clough, courtesy of Weidenfeld & Nicholson. All reasonable efforts have been made by the author and the publisher to trace the copyright holders of the quotations contained in this publication. In the event that any of the untraceable copyright holders comes forward after the publication of this edition, the author and the publishers will endeavour to rectify the situation accordingly. The main organs of the body 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 die 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 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 subtitle 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 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 ‘bottomup’, 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 investigators 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. However, that was the direction western medicine followed, and, bolstered by science at large, it generated a powerful medicine, 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 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 hygiene 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. The medicine of antiquity, transmitted to Islam and then back to the medieval West and remaining powerful throughout the Renaissance, paid great attention to general health maintenance through regulation of diet, exercise, hygiene and lifestyle. In the absence of decisive anatomical and physiological expertise, and without a powerful arsenal of cures and surgical skills, the ability to diagnose and make prognoses was highly valued, and an intimate physician-patient relationship was fostered. The teachings of antiquity, which remained authoritative until the eighteenth century and still supply subterranean reservoirs of medical folklore, were more successful in assisting people to cope with chronic conditions and soothing lesser ailments than in conquering life-threatening infections which became endemic and epidemic in the civilized world: leprosy, plague, smallpox, measles, and, later, the ‘filth diseases’ (like typhus) associated with urban squalor. This personal tradition of bedside medicine long remained popular in the West, as did its equivalents in Chinese and Ayurvedic medicine. But in Europe it was supplemented and challenged by the creation of a more ‘scientific’ medicine, grounded, for the first time, upon experimental anatomical and physiological investigation, epitomized from the fifteenth century by the dissection techniques which became central to medical education. Landmarks in this programme include the publication of De humani corporis fabrica (1543) by the Paduan professor, Andreas Vesalius, a momentous anatomical atlas and a work which challenged truths received since Galen; and William Harvey’s De motu cordis (1628) which put physiological inquiry on the map by experiments demonstrating the circulation of the blood and the heart’s role as a pump. Post-Vesalian investigations dramatically advanced knowledge of the structures and functions of the living organism. Further inquiries brought the unravelling of the lymphatic system and the lacteals, and the eighteenth and nineteenth centuries yielded a finer grasp of the nervous system and the operations of the brain. With the aid of microscopes and the laboratory, nineteenth-century investigators explored the nature of body tissue and pioneered cell biology; pathological anatomy came of age. Parallel developments in organic chemistry led to an understanding of respiration, nutrition, the digestive system and deficiency diseases, and founded such specialities as endocrinology. The twentieth century became the age of genetics and molecular biology. Nineteenth-century medical science made spectacular leaps forward in the understanding of infectious diseases. For many centuries, rival epidemiological theories had attributed fevers to miasmas (poisons in the air, exuded from rotting animal and vegetable material, the soil, and standing water) or to contagion (person-to-person contact). From the 1860s, the rise of bacteriology, associated especially with Louis Pasteur in France and Robert Koch in Germany, established the role of micro organic pathogens. Almost for the first time in medicine, bacteriology led directly to dramatic new cures. In the short run, the anatomically based scientific medicine which emerged from Renaissance universities and the Scientific Revolution contributed more to knowledge than to health. Drugs from both the Old and New Worlds, notably opium and Peruvian bark (quinine) became more widely available, and mineral and metal-based pharmaceutical preparations enjoyed a great if dubious vogue (e.g., mercury for syphilis). But the true pharmacological revolution began with the introduction of sulfa drugs and antibiotics in the twentieth century, and surgical success was limited before the introduction of anaesthetics and antiseptic operating-room conditions in the mid nineteenth century. Biomedical understanding long outstripped breakthroughs in curative medicine, and the retreat of the great lethal diseases (diphtheria, typhoid, tuberculosis and so forth) was due, in the first instance, more to urban improvements, superior nutrition and public health than to curative medicine. The one early striking instance of the conquest of disease – the introduction first of smallpox inoculation and then of vaccination – came not through ‘science’ but through embracing popular medical folklore. From the Middle Ages, medical practitioners organized themselves professionally in a pyramid with physicians at the top and surgeons and apothecaries nearer the base, and with other healers marginalized or vilified as quacks. Practitioners’ guilds, corporations and colleges received royal approval, and medicine was gradually incorporated into the public domain, particularly in German-speaking Europe where the notion of ‘medical police’ (health regulation and preventive public health) gained official backing in the eighteenth century. The state inevitably played the leading role in the growth of military and naval medicine, and later in tropical medicine. The hospital sphere, however, long remained largely the Church’s responsibility, especially in Roman Catholic parts of Europe. Gradually the state took responsibility for the health of emergent industrial society, through public health regulation and custody of the insane in the nineteenth century, and later through national insurance and national health schemes. These latter developments met fierce opposition from a medical profession seeking to preserve its autonomy against encroaching state bureaucracies. The latter half of the twentieth century has witnessed the continued phenomenal progress of capital-intensive and specialized scientific medicine: transplant surgery and biotechnology have captured the public imagination. Alongside, major chronic and psychosomatic disorders persist and worsen – jocularly expressed as the ‘doing better but feeling worse’ syndrome – and the basic health of the developing world is deteriorating. This situation exemplifies and perpetuates a key facet and paradox of the history of medicine: the unresolved disequilibrium between, on the one hand, the remarkable capacities of an increasingly powerful science-based biomedical tradition and, on the other, the wider and unfulfilled health requirements of economically impoverished, colonially vanquished and politically mismanaged societies. Medicine is an enormous achievement, but what it will achieve practically for humanity, and what those who hold the power will allow it to do, remain open questions. The late E. P. Thompson (1924–1993) warned historians against what he called the enormous condescension of posterity. I have tried to understand the medical systems I discuss rather than passing judgment on them; I have tried to spell them out in as much detail as space has permitted, because engagement with detail is essential if the cognitive power of medicine is to be appreciated. Eschewing anachronism, judgmentalism and history by hindsight does not mean denying that there are ways in which medical knowledge has progressed. Harvey’s account of the cardiovascular system was more correct than Galen’s; the emergence of endocrinology allowed the development in the 1920s of insulin treatments which saved the lives of diabetics. But one must not assume that diabetes then went away: no cure has been found for that still poorly understood disease, and it continues to spread as a consequence of western lifestyles. Indeed one could argue that the problem is now worse than when insulin treatment was discovered. Avoiding condescension equally does not mean one must avoid ‘winners’ history. This book unashamedly gives more space to the Greeks than the Goths, more attention to Hippocrates than to Greek rootgatherers, and stresses strands of development leading from Greek medicine to the biomedicine now in the saddle. I do not think that ‘winners’ should automatically be privileged by historians (I have myself written and advocated writing medical history from the patients’ view), but there is a good reason for bringing the winners to the foreground – not because they are ‘best’ or ‘right’ but because they are powerful. One can study winners without siding with them. Writing this book has not only made me more aware than usual of my own ignorance; it has brought home the collective and largely irremediable ignorance of historians about the medical history of mankind. Perhaps the most celebrated physician ever is Hippocrates yet we know literally nothing about him. Neither do we know anything concrete about most of the medical encounters there have ever been. The historical record is like the night sky: we see a few stars and group them into mythic constellations. But what is chiefly visible is the darkness. CHAPTER II THE ROOTS OF MEDICINE PEOPLES AND PLAGUES . The climate was clement, nature freely bestowed her bounty upon mankind, no lethal predators lurked, the lion lay down with the lamb and peace reigned. In that blissful long-lost Arcadia, according to the Greek poet Hesiod writing around 700 BC, life was ‘without evils, hard toil, and grievous disease’. All changed. Thereafter, wrote the poet, ‘thousands of miseries roam among men, the land is full of evils and full is the sea. Of themselves, diseases come upon men, some by day and some by night, and they bring evils to the mortals.’ The Greeks explained the coming of pestilences and other troubles by the fable of Pandora’s box. Something similar is offered by JudaeoChristianity. Disguised in serpent’s clothing, the Devil seduces Eve into tempting Adam to taste the forbidden fruit. By way of punishment for that primal disobedience, the pair are banished from Eden; Adam’s sons are condemned to labour by the sweat of their brow, while the daughters of Eve must bring forth in pain; and disease and death, unknown in the paradise garden, become the iron law of the post-lapsarian world, thenceforth a vale of tears. As in the Pandora fable and scores of parallel legends the world over, the Fall as revealed in Genesis explains how suffering, disease and death become the human condition, as a IN THE BEGINNING WAS THE GOLDEN AGE consequence of original sin. The Bible closes with foreboding: ‘And I looked, and behold a pale horse’ prophesied the Book of Revelation: ‘and his name that sat on him was Death, and Hell followed with him. And power was given unto them over the fourth part of the earth, to kill with sword, and with hunger, and with death, and with the beasts of the earth.’ Much later, the eighteenth-century physician George Cheyne drew attention to a further irony in the history of health. Medicine owed its foundation as a science to Hippocrates and his successors, and such founding fathers were surely to be praised. Yet why had medicine originated among the Greeks? It was because, the witty Scotsman explained, being the first civilized, intellectual people, with leisure to cultivate the life of the mind, they had frittered away the rude vitality of their warrior ancestors – the heroes of the Iliad- and so had been the first to need medical ministrations. This ‘diseases of civilization, paradox had a fine future ahead of it, resonating throughout Nietzsche and Freud’s Civilization and its Discontents(1930). Thus to many, from classical poets up to the prophets of modernity, disease has seemed the dark side of development, its Jekyll-and-Hyde double: progress brings pestilences, society sickness. Stories such as these reveal the enigmatic play of peoples, plagues and physicians which is the thread of this book, scotching any innocent notion that the story of health and medicine is a pageant of progress. Pandora’s box and similar just-so stories tell a further tale moreover, that plagues and pestilences are not acts of God or natural hazards; they are of mankind’s own making. Disease is a social development no less than the medicine that combats it. In the beginning . . . Anthropologists now maintain that some five million years ago in Africa there occurred the branching of the primate line which led to the first ape men, the low-browed, big-jawed hominid Australopithecines. Within a mere three million years Homo erectus had emerged, our first entirely upright, large-brained ancestor, who learned how to make fire, use stone tools, and eventually developed speech. Almost certainly a carnivorous hunter, this palaeolithic pioneer fanned out a million years or so ago from Africa into Asia and Europe. Thereafter a direct line leads to Homo sapiens who emerged around 150,000 BC. The life of early mankind was not exactly arcadian. Archaeology and paleopathology give us glimpses of forebears who were often malformed, racked with arthritis and lamed by injuries – limbs broken in accidents and mending awry. Living in a dangerous, often harsh and always unpredictable environment, their lifespan was short. Nevertheless, prehistoric people escaped many of the miseries popularly associated with the ‘fall’; it was later developments which exposed their descendants to the pathogens that brought infectious disease and have since done so much to shape human history. The more humans swarmed over the globe, the more they were themselves colonized by creatures capable of doing harm, including parasites and pathogens. There have been parasitic helminths (worms), fleas, ticks and a host of arthropods, which are the bearers of ‘arbo’ (arthropod-borne) infections. There have also been the micro-organisms like bacteria, viruses and protozoans. Their very rapid reproduction rates within a host provoke severe illness but, as if by compensation, produce in survivors immunity against reinfection. All such disease threats have been and remain locked with humans in evolutionary struggles for the survival of the fittest, which have no master plot and grant mankind no privileges. Despite carbon-14 and other sophisticated techniques used by palaeopathologists, we lack any semblance of a day-to-day health chart for early Homo sapiens. Theories and guesswork can be supported by reference to so-called ‘primitive’ peoples in the modern world, for instance Australian aborigines, the Hadza of Tanzania, or the !Kung San bush people of the Kalahari. Our early progenitors were hunters and gatherers. Pooling tools and food, they lived as nomadic opportunistic omnivores in scattered familial groups of perhaps thirty or forty. Infections like smallpox, measles and flu must have been virtually unknown, since the micro-organisms that cause contagious diseases require high population densities to provide reservoirs of susceptibles. And because of the need to search for food, these small bands did not stay put long enough to pollute water sources or accumulate the filth that attracts disease-spreading insects. Above all, isolated hunter-foragers did not tend cattle and the other tamed animals which have played such an ambiguous role in human history. While meat and milk, hides and horns made civilization possible, domesticated animals proved perennial and often catastrophic sources of illness, for infectious disease riddled beasts long before spreading to humans. Our ‘primitive’ ancestors were thus practically free of the pestilences that ambushed their ‘civilized’ successors and have plagued us ever since. Yet they did not exactly enjoy a golden age, for, together with dangers, injuries and hardships, there were ailments to which they were susceptible. Soil-borne anaerobic bacteria penetrated through skin wounds to produce gangrene and botulism; anthrax and rabies were picked up from animal predators like wolves; infections were acquired through eating raw animal flesh, while game would have transmitted the microbes of relapsing fever (like typhus, a louse-borne disease), brucellosis and haemorrhagic fevers. Other threats came from organisms co-evolving with humans, including tapeworms and such bacteria as Treponema, the agent of syphilis, and the similar skin infection, yaws. Hunter-gatherers being omnivores, they were probably not malnourished, at least not until rising populations had hunted to extinction most of the big game roaming the savannahs and prairies. Resources and population were broadly in balance. Relative freedom from disease encouraged numbers to rise, but all were prey to climate, especially during the Ice Age which set in from around 50,000 BC. Famine took its toll; lives would have been lost in hunting and skirmishing; childbirth was hazardous, fertility probably low, and infanticide may have been practised. All such factors kept numbers in check. For tens of thousands of years there was ample territory for dispersal, as pressure on resources drove migration ‘out of Africa’ into all corners of the Old World, initially to the warm regions of Asia and southern Europe, but then farther north into less hospitable climes. These nomadic ways continued until the end of the last Ice Age (the Pleistocene) around 12,000–10,000 years ago brought the invention of agriculture. Contrary to the Victorian assumption that farming arose out of mankind’s inherent progressiveness, it is now believed that tilling the soil began because population pressure and the depletion of game supplies left no alternative: it was produce more or perish. By around 50,000 B c, mankind had spilled over from the Old World to New Guinea and Australasia, and by 10,000 BC (perhaps much earlier) to the Americas as well (during the last Ice Age the lowering of the oceans made it possible to cross by land bridge from Siberia to Alaska). But when the ice caps melted around ten thousand years ago and the seas rose once more, there were no longer huge tracts of land filled with game but empty of humans and so ripe for colonization. Mankind faced its first ecological crisis – its first survival test. Necessity proved the mother of invention, and Stone Age stalkers, faced with famine – elk and gazelle had thinned out, leaving hogs, rabbits and rodents – were forced to grow their own food and settle in one place. Agriculture enhanced mankind’s capacity to harness natural resources, selectively breeding wild grasses into domesticated varieties of grains, and bringing dogs, cattle, sheep, goats, pigs, horses and poultry under control. This change had the rapidity of a revolution: until around 10,000 years ago, almost all human groups were hunter-gatherers, but within a few thousand years cultivators and pastoralists predominated. The ‘neolithic revolution’ was truly epochal. In the fertile crescent of the Middle East, wheat, barley, peas and lentils were cultivated, and sheep, pigs and goats herded; the neolithic peoples of south-east Asia exploited rice, sweet potatoes, ducks and chickens; in Mesoamerica, it was maize, beans, cassava, potatoes and guinea pigs. The land which a nomadic band would have stripped like locusts before moving on was transformed by new management techniques into a resource reservoir capable of supporting thousands, year in, year out. And once agriculture took root, with its systematic planting of grains and lentils and animal husbandry, numbers went on spiralling, since more could be fed. The labour-intensiveness of clearing woodland and scrub, weeding fields, harvesting crops and preparing food encouraged population growth and the formation of social hierarchies, towns, courts and kingdoms. But while agriculture rescued people from starvation, it unleashed a fresh danger: disease. The agricultural revolution ensured human domination of planet earth: the wilderness was made fertile, the forests became fields, wild beasts were tamed or kept at bay; but pressure on resources presaged the disequilibrium between production and reproduction that provoked later Malthusian crises, as well as leading to ecological deterioration. As hunters and gatherers became shepherds and farmers, the seeds of disease were sown. Prolific pathogens once exclusive to animals were transferred to swineherds and goatherds, ploughmen and horsemen, initiating the ceaseless evolutionary adaptations which have led to a current situation in which humans share no fewer than sixty-five micro-organic diseases with dogs (supposedly man’s best friend), and only slightly fewer with cattle, sheep, goats, pigs, horses and poultry. Many of the worst human diseases were created by proximity to animals. Cattle provided the pathogen pool with tuberculosis and viral poxes like smallpox. Pigs and ducks gave humans their influenzas, while horses brought rhinoviruses and hence the common cold. Measles, which still kills a million children a year, is the result of rinderpest (canine distemper) jumping between dogs or cattle and humans. Moreover, cats, dogs, ducks, hens, mice, rats and reptiles carry bacteria like Salmonella, leading to often fatal human infections; water polluted with animal faeces also spreads polio, cholera, typhoid, viral hepatitis, whooping cough and diphtheria. Settlement helped disease to settle in, attracting disease-spreading insects, while worms took up residence within the human body. Parasitologists and palaeopathologists have shown how the parasitic roundworm Ascaris, a nematode growing to over a foot long, evolved in humans, probably from pig ascarids, producing diarrhoea and malnutrition. Other helminths or wormlike fellow-travellers became common in the human gut, including the Enterobius (pinworm or threadworm), the yards-long hookworm, and the filarial worms which cause elephantiasis and African river blindness. Diseases also established themselves where agriculture depended upon irrigation – in Mesopotamia, Egypt, India and around the Yellow (Huang) River in China. Paddyfields harbour parasites able to penetrate the skin and enter the bloodstream of barefoot workers, including the forked-tailed blood fluke Schistosoma which utilizes aquatic snails as a host and causes bilharzia or schistosomiasis (graphically known as ‘big belly’), provoking mental and physical deterioration through the chronic irritation caused by the worm. Investigation of Egyptian mummies has revealed calcified eggs in liver and kidney tissues, proving the presence of schistosomiasis in ancient Egypt. (Mummies tell us much more about the diseases from which Egyptians suffered; these included gallstones, bladder and kidney stones, mastoiditis and numerous eye diseases, and many skeletons show evidence of rheumatoid arthritis.) In short, permanent settlement afforded golden opportunities for insects, vermin and parasites, while food stored in granaries became infested with insects, bacteria, fungoid toxins and rodent excrement. The scales of health tipped unfavourably, with infections worsening and human vitality declining.* Moreover, though agriculture enabled more mouths to be fed, it meant undue reliance on starchy cereal monocultures like maize, high in calories but low in proteins, vitamins and minerals; reduced nutritional levels allowed deficiency diseases like pellagra, marasmus, kwashiorkor and scurvy to make their entry onto the human stage. Stunted people are more vulnerable to infections, and it is a striking comment on ‘progress’ that neolithic skeletons are typically some inches shorter than their palaeolithic precursors. MALARIA Settlement also brought malaria. ‘There is no doubt’, judged the distinguished Australian immunologist, Macfarlane Burnet (1899–1985), ‘that malaria has caused the greatest harm to the greatest number’ – not through cataclysms, as with bubonic plague, but through its continual winnowing effect. First in sub-Saharan Africa and elsewhere since, conversion of forests into farmland has created environments tailormade for mosquitoes: warm waterholes, furrows and puddles ideal for rapid breeding. Malaria is worth pausing over, since it has coexisted with humans for thousands of years and remains out of control across much of the globe. The symptoms of malarial fevers were familiar to the Greeks, but were not explained until the advent of tropical medicine around 1900. They are produced by the microscopic protozoan parasite Plasmodium, which lives within the body of an Anopheles mosquito, and is transmitted to humans through mosquito bites. The parasites move through the bloodstream to the liver, where they breed during an incubation stage of a couple of weeks. Returning to the blood, they attack red blood cells, which break down, leading to waves of violent chills and high fever. Malarial parasites have distinct periodicities. Plasmodium vivax, the organism causing benign tertian malaria, once present in the English fenlands, has an incubation period of ten to seventeen days. The fever lasts from two to six hours, returning every third day (hence ‘tertian’); marked by vomiting and diarrhoea, such attacks may recur for two months or longer. In time, as Greek doctors observed, the spleen enlarges, and the patient becomes anaemic and sometimes jaundiced. Quartan malaria, caused by Plasmodium malariae, is another mild variety. Malignant tertian malaria, caused by Plasmodium falciparum, is the most lethal, producing at least 95 per cent of all malarial deaths. The incubation period is shorter but the fever more prolonged; it may be continuous, remittent or intermittent. Plasmodium falciparum proliferates fast, producing massive destruction of red blood cells and hence dangerous anaemia; the liver and spleen also become enlarged. Malaria may sometimes appear as quotidian fever, with attacks lasting six to twelve hours – the result of multiple infection. Patients may also develop malarial cachexia, with yellowing of the skin and severe spleen and liver enlargement; autopsy shows both organs darkened with a black pigment derived from the haemoglobin of the destroyed red blood cells. What the ancients called melancholy may have been a malarial condition. Malaria shadowed agricultural settlements. From Africa, it became established in the Near and Middle East and the Mediterranean littoral. The huge attention Graeco-Roman medicine paid to ‘remittent fevers’ shows how seriously the region was affected, and some historians maintain the disease played its part in the decline and fall of the Roman empire. Within living memory, malaria remained serious in the Roman Campagna and the Pontine marshes along Italy’s west coast. Coastal Africa was and remains heavily malarial, as are the Congo, the Niger and hundreds of other river basins. Indigenous West African populations developed a genetically controlled characteristic, the ‘sicklecell’, which conferred immunity against virulent Plasmodium falciparum. But, though protective, this starves its bearers, who are prone to debility and premature death: typical of such evolutionary trade-offs, gains and losses are finely balanced. India was also ripe for malarial infection. Ayurvedic medical texts (see Chapter Six) confirm the antiquity of the disease in the subcontinent. China, too, became heavily infected, especially the coastal strip from Shanghai to Macao. And from the sixteenth century Europeans shipped it to Mesoamerica: vivax malaria went to the New World in the blood of the Spanish conquistadores, while falciparum malaria arrived with the African slaves whom the Europeans imported to replace the natives they and their pestilences had wiped out. Malaria was just one health threat among many which set in with civilization as vermin learned to cohabit with humans, insects spread gastroenteric disorders, and contact with rodents led to human rickettsial (lice-, mite- and tick-borne) arbo diseases like typhus. Despite such infections encouraged by dense settlement and its waste and dirt, man’s restless inventive energies ensured that communities, no matter how unhealthy, bred rising populations; and more humans spawned more diseases in upward spirals, temporarily and locally checked but never terminated. Around 10,000 BC, before agriculture, the globe’s human population may have been around 5 million; by 500 BC it had probably leapt to 100 million; by the second century AD that may have doubled; the 1990 figure was some 5,292 million, with projections suggesting 12 billion by 2100. Growing numbers led to meagre diets, the weak and poor inevitably bearing the brunt. But though humans were often malnourished, parasiteriddled and pestilence-smitten, they were not totally defenceless. Survivors of epidemics acquired some protection, and the mechanisms of evolution meant that these acquired sophisticated immune systems enabling them to coexist in a ceaseless war with their micro-organic assailants. Immunities passed from mothers across the placenta or through breast-feeding gave infants some defence against germ invasion. Tolerance was likewise developed towards parasitic worms, and certain groups developed genetic shields, as with the sickle-cell trait. Biological adaptation might thus take the edge off lethal afflictions. THE ERA OF EPIDEMICS Some diseases, however, were not so readily coped with: those caused by the zoonoses (animal diseases transmissible to man) which menaced once civilization developed. By 3000 BC cities like Babylon, with populations of scores of thousands, were rising in Mesopotamia and Egypt, in the Indus Valley and on the Yellow River, and later in Mesoamerica. In the Old World, such settlements often maintained huge cattle herds, from which lethal pathogens, including smallpox, spread to humans, while originally zoognostic conditions – diphtheria, influenza, chicken-pox, mumps – and other illnesses also had a devastating impact. Unlike malaria, these needed no carriers; being directly contagious, they spread readily and rapidly. The era of epidemics began. And though some immunity would develop amongst the afflicted populations, the incessant outreach of civilization meant that merchants, mariners and marauders would inevitably bridge pathogen pools, spilling diseases onto virgin susceptibles. One nation’s familiar ‘tamed’ disease would be another’s plague, as trade, travel and war detonated pathological explosions. The immediate consequence of the invasion of a town by smallpox or another infection was a fulminating epidemic and subsequent decimation. Population recovery would then get under way, only for survivors ‘heirs to be blitzed by the same or a different pestilence, and yet another, in tide upon tide. Settlements big enough to host such contagions might shrink to become too tiny. With almost everybody slain or immune, the pestilences would withdraw, victims of their own success, moving on to storm other virgin populations, like raiders seeking fresh spoils. New diseases thus operated as brutal Malthusian checks, sometimes shaping the destinies of nations. Cities assumed a decisive epidemiological role, being magnets for pathogens no less than people. Until the nineteenth century, towns were so insanitary that their populations never replaced themselves by reproduction, multiplying only thanks to the influx of rural surpluses who were tragically infection-prone. In this challenge and response process, sturdy urban survivors turned into an immunological elite – a virulently infectious swarm perilous to less seasoned incomers, confirming the notoriety of towns as death-traps. The Old Testament records the epidemics the Lord hurled upon the Egypt of the pharaohs, and from Greek times historians noted their melancholy toll. The Peloponnesian War of 431 to 404 BC, the ‘world war’ between Athens and Sparta, spotlights the traffic in pestilence that came with civilization. Before that war the Greeks had suffered from malaria and probably tuberculosis, diphtheria and influenza, but they had been spared truly calamitous plagues. Reputedly beginning in Africa and spreading to Persia, an unknown epidemic hit Greece in 430 BC, and its impact on Athens was portrayed by Thucydides (460 – after 404 BC). Victims were poleaxed by headaches, coughing, vomiting, chest pains and convulsions. Their bodies became reddish or livid, with blisters and ulcers; the malady often descended into the bowels before death spared sufferers further misery. The Greek historian thought it killed a quarter of the Athenian troops, persisting on the mainland for a farther four years and annihilating a similar proportion of the population. What was it? Smallpox, plague, measles, typhus, ergotism and even syphilis have been proposed in a parlour game played by epidemiologists. Whatever it was, by killing or immunizing them, it destroyed the Greeks’ ability to host it and, proving too virulent for its own good, the disease disappeared. With it passed the great age of Athens. Most early nations probably experienced such disasters, but Greece alone had a Thucydides to record it. Epidemics worsened with the rise of Rome. With victories in Macedonia and Greece (146 BC), Persia (64 BC) and finally Egypt (30 BC), the Roman legions vanquished much of the known world, but deadly pathogens were thus given free passage around the empire, spreading to the Eternal City itself. The first serious outbreak, the so-called Antonine plague (probably smallpox which had smouldered in Africa or Asia before being brought back from the Near East by Roman troops) slew a quarter of the inhabitants in stricken areas between AD 165 and 180, some five million people in all. A second, between AD 211 and 266, reportedly destroyed some 5,000 a day in Rome at its height, while scourging the countryside as well. The virulence was immense because populations had no resistance. Smallpox and measles had joined the Mediterranean epidemiological melting-pot, alongside the endemic malaria. Wherever it struck a virgin population, measles too proved lethal. There are some recent and well-documented instances of such strikes. In his Observations Made During the Epidemic of Measles on the Faroe Islands in the Year 1846, Peter Panum (1820–85) reported how measles had attacked about 6,100 out of 7,864 inhabitants on a remote island which had been completely free of the disease for sixty-five years. In the nineteenth century, high mortality was also reported in measles epidemics occurring in virgin soil populations (‘island laboratories’) in the Pacific Ocean: 40,000 deaths in a population of 150,000 in Hawaii in 1848, 20,000 (perhaps a quarter of the population) on Fiji in 1874. Improving communications also widened disease basins in the Middle East, the Indian subcontinent, South Asia and the Far East. Take Japan: before AD 552, the archipelago had apparently escaped the epidemics blighting the Chinese mainland. In that year, Buddhist missionaries visited the Japanese court, and shortly afterwards smallpox broke out. In 585 there was a further eruption of either smallpox or measles. Following centuries brought waves of epidemics every three or four years, the most significant being smallpox, measles, influenza, mumps and dysentery. This alteration of occasional epidemic diseases into endemic ones typical of childhood – it mirrors the domestication of animals – represents a crucial stage in disease ecology. Cities buffeted by lethal epidemics which killed or immunized so many that the pathogens themselves disappeared for lack of hosts, eventually became big enough to house sufficient non-immune individuals to retain the diseases permanently; for this an annual case total of something in the region of 5,000–40,000 may be necessary. Measles, smallpox and chickenpox turned into childhood ailments which affected the young less severely and conferred immunity to future attacks. The process marks an epidemiological watershed. Through such evolutionary adaptations – epidemic diseases turning endemic – expanding populations accommodated and surmounted certain oncelethal pestilences. Yet they remained exposed to other dire infections, against which humans were to continue immunologically defenceless, because they were essentially diseases not of humans but of animals. One such is bubonic plague, which has struck humans with appalling ferocity whenever populations have been caught up in a disease net involving rats, fleas and the plague bacillus (Yersinia pestis ). Diseases like plague, malaria, yellow fever, and others with animal reservoirs are uniquely difficult to control. PLAGUE Bubonic plague is basically a rodent disease. It strikes humans when infected fleas, failing to find a living rat once a rat host has been killed, pick a human instead. When the flea bites its new host, the bacillus enters the bloodstream. Filtered through the nearest lymph node, it leads to the characteristic swelling (bubo) in the neck, groin or armpit. Bubonic plague rapidly kills about two-thirds of those infected. There are two other even more fatal forms: septicaemic and, deadliest of all, pneumonic plague, which doesn’t even need an insect vector, spreading from person to person directly via the breath. The first documented bubonic plague outbreak occurred, predictably enough, in the Roman empire. The plague of Justinian originated in Egypt i n AD 540; two years later it devastated Constantinople, going on to massacre up to a quarter of the eastern Mediterranean population, before spreading to western Europe and ricocheting around the Mediterranean for the next two centuries. Panic, disorder and murder reigned in the streets of Constantinople, wrote the historian Procopius: up to 10,000 people died each day, until there was no place to put the corpses. When this bout of plague ended, 40 per cent of the city’s population were dead. It was a subsequent plague cycle, however, which made the greatest impact. Towards 1300 the Black Death began to rampage through Asia before sweeping westwards through the Middle East to North Africa and Europe. Between 1346 and 1350 Europe alone lost perhaps twenty million to the disease. And this pandemic was just the first wave of a bubonic pestilence that raged until about 1800 (see Chapter 5). Trade, war and empire have always sped disease transmission between populations, a dramatic instance being offered by early modern Spain. The cosmopolitan Iberians became subjects of a natural Darwinian experiment, for their Atlantic and Mediterranean seaports served as clearing-houses for swarms of diseases converging from Africa, Asia and the Americas. Survival in this hazardous environment necessitated becoming hyper-immune, weathering a hail of childhood diseases – smallpox, measles, diphtheria and the like, gastrointestinal infections and other afflictions rare today in the West. The Spanish conquistadores who invaded the Americas were, by consequence, immunological supermen, infinitely more deadly than ‘typhoid Mary’; disease gave them a fatal superiority over the defenceless native populations they invaded. TYPHUS Though the Black Death ebbed away from Europe, war and the movements of migrants ensured that epidemic disease did not go away, and Spain, as one of the great crossroads, formed a flashpoint of disease. Late in 1489, in its assault on Granada, Islam’s last Iberian stronghold, Spain hired some mercenaries who had lately been in Cyprus fighting the Ottomans. Soon after their arrival, Spanish troops began to go down with a disease never before encountered and possessing the brute virulence typical of new infections: typhus. It had probably emerged in the Near East during the Crusades before entering Europe where Christian and Muslim armies clashed. It began with headache, rash and high fever, swelling and darkening of the face; next came delirium and the stupor giving the disease its name – typhos is Greek for ‘smoke’. Inflammation led to gangrene that rotted fingers and toes, causing a hideous stench. Spain lost 3,000 soldiers in the siege but six times as many to typhus. Having smuggled itself into Spain, typhus filtered into France and beyond. In 1528, with the Valois (French) and Habsburg (Spanish) dynasties vying for European mastery, it struck the French army encircling Naples; half the 28,000 troops died within a month, and the siege collapsed. As a result, Emperor Charles V of Spain was left master of Italy, controlling Pope Clement VII – with important implications for Henry VIII’s marital troubles and the Reformation in England. With the Holy Roman Empire fighting the Turks in the Balkans, typhus gained a second bridgehead into Europe. In 1542, the disease killed 30,000 Christian soldiers on the eastern front; four years later, it struck the Ottomans, terminating their siege of Belgrade; while by 1566 the Emperor Maximilian II had so many typhus victims that he was driven to an armistice. His disbanded troops relayed the disease back to western Europe, and so to the New World, where it joined measles and smallpox in ravaging Mexico and Peru. Typhus subsequently smote Europe during the Thirty Years War (1618–48), and remained widespread, devastating armies as ‘camp fever’, dogging beggars (road fever), depleting jails (jail fever) and ships (ship fever). It was typhus which joined General Winter to turn Napoleon’s Russian invasion into a rout. The French crossed into Russia in June 1812. Sickness set in after the fall of Smolensk. Napoleon reached Moscow in September to find the city abandoned. During the next five weeks, the grande armée suffered a major typhus epidemic. By the time Moscow was evacuated, tens of thousands had fallen sick, and those unfit to travel were abandoned. Thirty thousand cases were left to die in Vilna alone, and only a trickle finally reached Warsaw. Of the 600,000 men in Napoleon’s army, few returned, and typhus was a major reason. Smallpox, plague and typhus indicate how war and conquest paved the way for the progress of pathogens. A later addition, at least as far as the West was concerned, was cholera, the most spectacular ‘new’ disease of the nineteenth century. COLONIZATION AND INDUSTRIALIZATION Together with civilization and commerce, colonization has contributed to the dissemination of infections. The Spanish conquest of America has already been mentioned; the nineteenth-century scramble for Africa also caused massive disturbance of indigenous populations and environmental disruption, unleashing terrible epidemics of sleeping sickness and other maladies. Europeans exported tuberculosis to the ‘Dark Continent’, especially once native labourers were jammed into mining compounds and the slums of Johannesburg. In the gold, diamond and copper producing regions of Africa, the operations of mining companies like De Beers and Union Minière de Haute Katanga brought family disruption and prostitution. Capitalism worsened the incidence of infectious and deficiency diseases for those induced or forced to abandon tribal ways and traditional economies – something which medical missionaries were pointing out from early in the twentieth century. While in the period after Columbus’s voyage, advances in agriculture, plant-breeding and crop exchange between the New and Old Worlds in some ways improved food supply, for those newly dependent upon a single staple crop the consequence could be one of the classic deficiency diseases: scurvy, beriberi or kwashiorkor (from a Ghanaian word meaning a disease suffered by a child displaced from the breast). Those heavily reliant on maize in Mesoamerica and later, after it was brought back by the conquistadores, in the Mediterranean, frequently fell victim to pellagra, caused by niacin deficiency and characterized by diarrhoea, dermatitis, dementia and death. Another product of vitamin B (thiamine) deficiency is beriberi, associated with Asian rice cultures. The Third World, however, has had no monopoly on dearth and deficiency diseases. The subjugation of Ireland by the English, complete around 1700, left an impoverished native peasantry ‘living in Filth and Nastiness upon Butter-milk and Potatoes, without a Shoe or stocking to their Feet’, as Jonathan Swift observed. Peasants survived through cultivating the potato, a New World import and another instance of how the Old World banked upon gains from the New. A wonderful source of nutrition, rich in vitamins B1, B2 and C as well as a host of essential minerals, potatoes kept the poor alive and well-nourished, but when in 1727 the oat crop failed, the poor ate their winter potatoes early and then starved. The subsequent famine led Swift to make his ironic ‘modest proposal’ as to how to handle the island’s surplus population better in future: a young healthy Child, well nursed is, at a Year old, a most delicious, nourishing and wholesome Food; whether Stewed, Roasted, Baked, or Boiled; and, I make no doubt, that it will equally serve in a Fricassee, or Ragout. . . I grant this Food will be somewhat dear, and therefore very proper for Landlords. With Ireland’s population zooming, disaster was always a risk. From a base of two million potato-eating peasants in 1700, the nation multiplied to five million by 1800 and to close on nine million by 1845. The potato island had become one of the world’s most densely populated places. When the oat and potato crops failed, starving peasants became prey to various disorders, notably typhus, predictably called ‘Irish fever’ by the landlords. During the Great Famine of 1845–7, typhus worked its way through the island; scurvy and dysentery also returned. Starving children aged so that they looked like old men. Around a million people may have died in the famine and in the next decades millions more emigrated. Only a small percentage of deaths were due directly to starvation; the overwhelming majority occurred from hunger-related disease: typhus, relapsing fevers and dysentery. The staple crops introduced by peasant agriculture and commercial farming thus proved mixed blessings, enabling larger numbers to survive but often with their immunological stamina compromised. There may have been a similar trade-off respecting the impact of the Industrial Revolution, first in Europe, then globally. While facilitating population growth and greater (if unequally distributed) prosperity, industrialization spread insanitary living conditions, workplace illnesses and ‘new diseases’ like rickets. And even prosperity has had its price, as Cheyne suggested. Cancer, obesity, gallstones, coronary heart disease, hypertension, diabetes, emphysema, Alzheimer’s disease and many other chronic and degenerative conditions have grown rapidly among today’s wealthy nations. More are of course now living long enough to develop these conditions, but new lifestyles also play their part, with cigarettes, alcohol, fatty diets and narcotics, those hallmarks of life in the West, taking their toll. Up to one third of all premature deaths in the West are said to be tobacco-related; in this, as in so many other matters, parts of the Third World are catching up fast. And all the time ‘new’ diseases still make their appearance, either as evolutionary mutations or as ‘old’ diseases flushed out of their local environments (their very own Pandora’s box) and loosed upon the wider world as a result of environmental disturbance and economic change. The spread of AIDS, Ebola, Lassa and Marburg fevers may all be the result of the impact of the West on the ‘developing’ world – legacies of colonialism. Not long ago medicine’s triumph over disease was taken for granted. At the close of the Second World War a sequence of books appeared in Britain under the masthead of ‘The Conquest Series’. These included The Conquest of Disease, The Conquest of Pain, The Conquest of Tuberculosis, The Conquest of Cancer, The Conquest of the Unknown and The Conquest of Brain Mysteries, and they celebrated ‘the many wonders of contemporary medical science today’. And this was before the further ‘wonder’ advances introduced after 1950, from tranquillizers to transplant surgery. A signal event was the world-wide eradication of smallpox in 1977. In spite of such advances, expectations of a conclusive victory over disease should always have seemed naive since that would fly in the face of a key axiom of Darwinian biology: ceaseless evolutionary adaptation. And that is something disease accomplishes far better than humans, since it possesses the initiative. In such circumstances it is hardly surprising that medicine has proved feeble against AIDS, because the human immunodeficiency virus (HIV) mutates rapidly, frustrating the development of vaccines and antiviral drugs. The systematic impoverishment of much of the Third World, the disruption following the collapse of communism, and the rebirth of an underclass in the First World resulting from the free-market economic policies dominant since the 1980s, have all assisted the resurgence of disease. In March 1997 the chairman of the British Medical Association warned that Britain was slipping back into the nineteenth century in terms of public health. Despite dazzling medical advances, world health prospects at the close of the twentieth century seem much gloomier than half a century ago. The symbiosis of disease with society, the dialectic of challenge and adaptation, success and failure, sets the scene for the following discussion of medicine. From around 2000 BC, medical ideas and remedies were written down. That act of recording did not merely make early healing accessible to us; it transformed medicine itself. But there is more to medicine than the written record, and the remainder of this chapter addresses wider aspects of healing – customary beliefs about illness and the body, the self and society – and glances at medical beliefs and practices before and beyond the literate tradition. MAKING SENSE OF SICKNESS Though prehistoric hunting and gathering groups largely escaped epidemics, individuals got sick. Comparison with similar groups today, for instance the Kalahari bush people, suggests they would have managed their health collectively, without experts. A case of illness or debility directly affected the well-being of the band: a sick or lame person is a serious handicap to a group on the move; hence healing rituals or treatment would be a public matter rather than (as Western medicine has come to see them) private. Anthropologists sometimes posit two contrasting ‘sick roles’: one in which the sick person is treated as a child, fed and protected during illness or incapacity; the other in which the sufferer either leaves the group or is abandoned or, as with lepers in medieval Europe, ritually expelled, becoming culturally ‘dead’ before they are biologically dead. Hunter-gatherer bands were more likely to abandon their sick than to succour them. With population rise, agriculture, and the emergence of epidemics, new medical beliefs and practices arose, reflecting growing economic, political and social complexities. Communities developed hierarchical systems, identified by wealth, power and prestige. With an emergent division of labour, medical expertise became the métier of particular individuals. Although the family remained the first line of defence against illness, it was bolstered by medicine men, diviners, witchsmellers and shamans, and in due course by herbalists, birth-attendants, bone-setters, barber-surgeons and healer-priests. When that first happened we cannot be sure. Cave paintings found in France, some 17,000 years old, contain images of men masked in animal heads, performing ritual dances; these may be the oldest surviving images of medicine-men. Highly distinctive was the shaman. On first encountering such folk healers, westerners denounced them as impostors. In 1763 the Scottish surgeon John Bell (1691–1780) described the ‘charming sessions’ he witnessed in southern Siberia: [the shaman] turned and distorted his body into many different postures, till, at last, he wrought himself up to such a degree of fury that he foamed at the mouth, and his eyes looked red and staring. He now started up on his legs, and fell a dancing, like one distracted, till he trod out the fire with his bare feet. These unnatural motions were, by the vulgar, attributed to the operations of a divinity. . . He now performed several legerdemain tricks; such as stabbing himself with a knife, and bringing it up at his mouth, running himself through with a sword and many others too trifling to mention. This Calvinist Scot was not going to be taken in by Asiatic savages: ‘nothing is more evident than that these shamans are a parcel of jugglers, who impose on the ignorant and credulous vulgar.’ Such a reaction is arrogantly ethnocentric: although shamans perform magical acts, including deliberate deceptions, they are neither fakes nor mad. Common in native American culture as well as Asia, the shaman combined the roles of healer, sorcerer, seer, educator and priest, and was believed to possess god-given powers to heal the sick and to ensure fertility, a good harvest or a successful hunt. His main healing techniques have been categorized as contagious magic (destruction of enemies, through such means as the use of effigies) and direct magic, involving rituals to prevent disease, fetishes, amulets (to protect against black magic), and talismans (for good luck). In 1912 Sir Baldwin Spencer (1860–1929) and F.J. Gillen (1856–1912) described the practices of the aborigine medicine-man in Central Australia: In ordinary cases the patient lies down, while the medicine man bends over him and sucks vigorously at the part of the body affected, spitting out every now and then pieces of wood, bone or stone, the presence of which is believed to be causing the injury and pain. This suction is one of the most characteristic features of native medical treatment, as pain in any part of the body is always attributed to the presence of some foreign body that must be removed. Stone-sucking is a symbolic act. As the foreign body had been introduced into the body of the sick man by a magical route, it had to be removed in like manner. For the medicine-man, the foreign body in his mouth attracts the foreign body in the patient. As such specialist healers emerged, and as labour power grew more valuable in structured agricultural and commercial societies, the appropriate ‘sick role’ shifted from abandonment to one modelled on child care. The exhausting physical labour required of farm workers encouraged medicines that would give strength; hence, together with drugs to relieve fevers, dysentery and pain, demand grew for stimulants and tonics such as tobacco, coca, opium and alcohol. In hierarchical societies like Assyria or the Egypt of the pharaohs, with their military-political elites, illness became unequally distributed and thus the subject of moral, religious and political teachings and judgments. Its meanings needed to be explained. Social stratification meanwhile offered fresh scope for enterprising healers; demand for medicines grew; social development created new forms of healing as well as of faith, ritual and worship; sickness needed to be rationalized and theorized. In short, with settlement and literacy, conditions were ripe for the development of medicine as a belief-system and an occupation. APPROACHES TO HEALING Like earthquakes, floods, droughts and other natural disasters, illness colours experiences, outlooks and feelings. It produces pain, suffering and fear, threatens the individual and the community, and raises the spectre of that mystery of mysteries – death. Small wonder impassioned and contested responses to sickness have emerged: notions of blame and shame, appeasement and propitiation, and teachings about care and therapeutics. Since sickness raises profound anxieties, medicine develops alongside religion, magic and social ritual. Nor is this true only of ‘primitive’ societies; from Job to the novels of Thomas Mann, the experience of sickness, ageing and death shapes the sense of the self and the human condition at large. AIDS has reminded us (were we in danger of forgetting) of the poignancy of sickness in the heyday of life. Different sorts of sickness beliefs took shape. Medical ethnologists commonly suggest a basic divide: natural causation theories, which view illness as a result of ordinary activities that have gone wrong – for example, the effects of climate, hunger, fatigue, accidents, wounds or parasites; and personal or supernatural causation beliefs, which regard illness as harm wreaked by a human or superhuman agency. Typically, the latter is deliberately inflicted (as by a sorcerer) through magical devices, words or rituals; but it may be unintentional, arising out of an innate capacity for evil, such as that possessed by witches. Pollution from an ‘unclean’ person may thus produce illness – commonly a corpse or a menstruating woman. Early beliefs ascribed special prominence to social or supernatural causes; illness was thus injury, and was linked with aggression. This book focuses mostly upon the naturalistic notions of disease developed by and since the Greeks, but mention should be made of the supernatural ideas prominent in non-literate societies and present elsewhere. Such ideas are often subdivided by scholars into three categories: mystical, in which illness is the automatic consequence of an act or experience; animistic, in which the illness-causing agent is a personal supernatural being; and magical, where a malicious human being uses secret means to make someone sick. The distribution of these beliefs varies. Africa abounds in theories of mystical retribution, in which broken taboos are to blame; ancestors are commonly blamed for sickness. Witchcraft, the evil eye and divine retribution are frequently used to explain illness in India, as they were in educated Europe up to the seventeenth century, and in peasant parts beyond that time. Animistic or volitional illness theories take various forms. Some blame objects for illness – articles which are taboo, polluting or dangerous, like the planets within astrology. Other beliefs blame people – sorcerers or witches. Sorcerers are commonly thought to have shot some illness-causing object into the victim, thus enabling healers to ‘extract’ it via spectacular rituals. The search for a witch may involve divination or public witch-hunts, with cathartic consequences for the community and calamity for the scapegoat, who may be punished or killed. Under such conditions, illness plays a key part in a community’s collective life, liable to disrupt it and lead to persecutions, in which witchfinders and medicine men assume a key role. There are also systems that hinge on spirits – and the recovery of lost souls. The spirits of the dead, or nature spirits like wood demons, are believed to attack the sick; or the patient’s own soul may go missing. By contrast to witchcraft, these notions of indirect causation allow for more nuanced explanations of the social troubles believed to cause illness; there need be no single scapegoat, and purification may be more general. Shamanistic healers will use their familiarity with worlds beyond to grasp through divination the invisible causes behind illness. Some groups use divining apparatus – shells, bones or entrails; a question will be put to an oracle and its answer interpreted. Other techniques draw on possession or trance to fathom the cause of sickness. Responses to sickness may take many forms. They may simply involve the sick person hiding away on his own, debasing himself with dirt and awaiting his fate. More active therapies embrace two main techniques – herbs and rituals. Medicines are either tonics to strengthen the patient or ‘poisons’ to drive off the aggressor. Choice of the right herbal remedy depends on the symbolic properties of the plant and on its empirical effects. Some are chosen for their material properties, others for their colour, shape or resonances within broader webs of symbolic meaning. But if herbs may be symbolic, they may also be effective; after much pooh-poohing of ‘primitive medicine’, pharmacologists studying ethnobotany now acknowledge that such lore provided healers with effective analgesics, anaesthetics, emetics, purgatives, diuretics, narcotics, cathartics, febrifuges, contraceptives and abortifacients. From the herbs traditionally in use, modern medicine has derived such substances as salicylic acid, ipecac, quinine, cocaine, colchicine, ephedrine, digitalis, ergot, and other drugs besides. Medicines are not necessarily taken only by the patient, for therapy is communal and in traditional healing it is the community that is being put to rights, the patient being simply the stand-in. Certain healing rituals are rites de passage, with phases of casting out and reincorporation; others are dramas; and often the patient is being freed from unseen forces (exorcism). Some rituals wash a person clean; others use smoke to drive harm out. A related approach, Dreckapotheke, involves dosing the patient with disgusting decoctions or fumigations featuring excrement, noxious insects, and so forth, which drive the demons away. A great variety of healing methods employ roots and leaves in elaborate magical rituals, and all communities practise surgery of some sort. Many tribes have used skin scarifications as a form of protection. Other kinds of body decoration, clitoridectomies and circumcision are common (circumcision was performed in Egypt from around 2000 BC). To combat bleeding, traditional surgeons used tourniquets or cauterization, or packed the wound with absorbent materials and bandaged it. The Masai in East Africa amputate fractured limbs, but medical amputation has been rare. There is archaeological evidence, however, from as far apart as France, South America and the Pacific that as early as 5000 BC trephining was performed, which involved cutting a small hole in the skull. Flint cutting tools were used to scrape away portions of the cranium, presumably to deliver sufferers from some devil tormenting the soul. Much skill was required and callous formations on the edges of the bony hole show that many of the patients survived. BODY LORE Illness is thus not just biological but social, and concepts of the body and its sicknesses draw upon powerful dichotomies: nature and culture, the sacred and the profane, the raw and the cooked. Body concepts incorporate beliefs about the body politic at large; communities with rigid caste and rank systems thus tend to prescribe rigid rules about bodily comportment. What is considered normal health and what constitutes sickness or impairment are negotiable, and the conventions vary from community to community and within subdivisions of societies, dependent upon class, gender and other factors. Maladies carry different moral charges. ‘Sick roles’ may range from utter stigmatization (common with leprosy, because it is so disfiguring) to the notion that the sick person is special or semi-sacred (the holy fool or the divine epileptic). An ailment can be a rite de passage, a childhood illness an essential preliminary to entry into adulthood. Death affords a good instance of the scope for different interpretations in the light of different criteria. The nature of ‘physical’ death is highly negotiable; in recent times western tests have shifted from cessation of spontaneous breathing to ‘brain death’. This involves more than the matter of a truer definition: it corresponds with western values (which prize the brain) and squares with the capacities of hospital technology. Some cultures think of death as a sudden happening, others regard dying as a process advancing from the moment of birth and continuing beyond the grave. Bodies are thus languages as well as envelopes of flesh; and sick bodies have eloquent messages for society. It became common wisdom in the West from around 1800 that the medicine of orientals and ‘savages’ was mere mumbo-jumbo, and had to be superseded. Medical missions moved into the colonies alongside their religious brethren, followed in due course by the massive health programmes of the modern international aid organizations. By all such means Europeans and Americans sought to stamp out indigenous practices and beliefs, from the African witchdoctors and spirit mediums to the vaidyas and hakims of Hindu and Islamic medicine in Asia. Native practices were grounded in superstition and were perilous to boot; colonial authorities moved in to prohibit practices and cults which they saw as medically, religiously or politically objectionable, thereby becoming arbiters of ‘good’ and ‘bad’ medicine. Western medicine grew aggressive, convinced of its unique scientific basis and superior therapeutic powers. This paralleled prejudices developing towards folk or religious medicine within Europe itself. The sixteenth-century French physician Laurent Joubert (1529–83) wrote a huge tome exposing ‘common fallacies’. Erreurs populaires [1578] systematically denounced the ‘vulgar errors’ and erroneous sayings of popular medicine regarding pregnancy, childbirth, lying-in, infant care, children’s diseases and so forth, insisting that ‘such errors can be most harmful to man’s health and even his life’. ‘Sometimes babies, boys as well as girls, are born with red marks on their faces, necks, shoulders or other parts of the body,’ Joubert noted. ‘It is said that this is because they were conceived while their mother had her period … But I believe that it is impossible that a woman should conceive during her menstrual flow.’ Another superstition was that whatever was imprinted upon the imagination of the mother at the time of conception would leave a mark on the body of her baby. Elite medicine sought to discredit health folklore, but popular medicine has by no means always been misguided or erroneous. Recent pharmacological investigations have demonstrated the efficacy of many traditional cures. It is now known, for instance, that numerous herbal decoctions – involving rue, savin, wormwood, pennyroyal and juniper – traditionally used by women to regulate fertility have some efficacy. Today’s ‘green pharmacy’ aims at the recovery of ancient popular medical lore, putting it to the scientific test. Once popular medicine had effectively been defeated and no longer posed a threat, scholarly interest in it grew, and great collections of ‘medical folklore’ and ‘medical magic’, stressing their quaintness, were published in the nineteenth century. But it is a gross mistake to view folk medicine as a sack of bizarre beliefs and weird and wonderful remedies. Popular medicine is based upon coherent conceptions of the body and of nature, rooted in rural society. Different body parts are generally represented as linked to the cosmos; health is conceived as a state of precarious equilibrium among components in a fluid system of relations; and healing mainly consists of re-establishing this balance when lost. Such medical beliefs depend on notions of opposites and similars. For example, to stop a headache judged to emanate from excessive heat, cold baths to the feet might be recommended; or to cure sciatica, an incision to the ear might be made on the side opposite to the pain. Traditional medicine views the body as the centre or the epitome of the universe, with manifold sympathies linking mankind and the natural environment. Analogy and signatures are recurrent organizing principles in popular medicine. By their properties (colour, form, smell, heat, humidity, and so on) the elements of nature signal their meaningful associations with the human body, well and sick. For instance, in most traditional medicine systems, red is used to cure disorders connected with blood; geranium or oil of St John’s wort are used against cuts. Yellow plants such as saffron crocus ( Crocus sativus) were chosen for jaundice, or the white spots on the leaves of lungwort (Pulmonaria officinalis) showed that the plant was good for lung disease, and so on. Sometimes it was argued that remedies had been put in places convenient for people to use. So, in England, the bark of the white willow (Salix alba) was valued for agues, because the tree grows in moist or wet soil, where agues chiefly abound, as the Revd Edmund Stone, of Chipping Norton in Oxfordshire, observed in his report to the Royal Society of London in 1763: the general maxim, that many natural maladies carry their cures along with them, or that their remedies lie not far from their causes, was so very apposite to this particular case, that I could not help applying it; and that this might be the intention of Providence here, I must own had some little weight with me. Maintaining health required understanding one’s body. This was both a simple matter (pain was directly experienced) and appallingly difficult, for the body’s interior was hidden. Unable to peer inside, popular wisdom relied upon analogy, drawing inferences from the natural world. Domestic life gave clues for body processes – food simmering on the hob became a natural symbol for its processing in the stomach – while magic, folksong and fable explained how conception and birth, growth, decay and death mirrored the seedtime and the harvest. The landscape contained natural signs: thus peasant women made fertility shrines out of springs. To fathom abnormalities and heal ailments, countryfolk drew upon the suggestive qualities of strange creatures like toads and snakes (their distinctive habits like hibernation or shedding skins implied a special command over life and death), and also the evocative profiles of landscape features like valleys and caves, while the phases of the moon so obviously correlated with the menstrual cycle. Nature prompted the idea that the healthy body had to flow. In an agrarian society preoccupied with the weather and with the changes of the seasons, the systems operating beneath the skin were intuitively understood as fluid: digestion, fertilization, growth, expulsion. Not structures but processes counted. In vernacular and learned medicine alike, maladies were thought to migrate round the body, probing weak spots and, like marauding bands, most perilous when they targeted central zones. Therapeutics, it was argued, should counter-attack by forcing or luring ailments to the extremities, like the feet, where they might be expelled as blood, pus or scabs. In such a way of seeing, a gouty foot might even be a sign of health, since the big toe typically afflicted was an extremity far distant from the vital organs: a foe in the toe was trouble made to keep its distance. In traditional medicine, as I have said, health is a state of precarious balance – being threatened, toppled and restored – between the body, the universe and society. More important than curing is the aim of preventing imbalance from occurring in the first place. Equilibrium is to be achieved by avoiding excess and pursuing moderation. Prevention lies in living in accord with nature, in harmony with the seasons and elements and the supernatural powers that haunt the landscape: purge the body in spring to clean it of corrupt humours, in summer avoid activities or foods which are too heating. Another preventative is good diet – an idea encapsulated in the later advice, ‘an apple a day keeps the doctor away’. Foods should be consumed which give strength and assimilate natural products which, resembling the body, are beneficial to it, such as wine and red meat: ‘meat makes flesh and wine makes blood’, runs a French proverb. The idea that life is in the blood is an old one. ‘Epileptic patients are in the habit of drinking the blood even of gladiators,’ rioted the Roman author Pliny (AD C. 23–79): ‘these persons, forsooth, consider it a most effectual cure for their disease, to quaff the warm, breathing, blood from man himself, and, as they apply their mouth to the wound, to draw forth his very life.’ Clear-cut distinctions have frequently been drawn between ‘science’ and ‘superstition’ but, as historians of popular culture today insist, in societies with both a popular and an elite tradition (high and low, or learned and oral cultures), there has always been complex two-way cultural traffic in knowledge, or more properly a continuum. While often aloof and dismissive, professional medicine has borrowed extensively from the folk tradition. Take, for instance, smallpox inoculation. There had long been some folk awareness in Europe of the immunizing properties of a dose of smallpox, but it was not until around 1700 that this knowledge was turned ...
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