Book Review

Medicine and the Five Senses

N Engl J Med 1994; 331:206-207July 21, 1994

Article

Medicine and the Five Senses
Edited by W.F. Bynum and Roy Porter. 331 pp., illustrated. New York, Cambridge University Press, 1993. $59.95. ISBN: 0-521-36114-1

The 14 papers in this book, originally presented at the Wellcome Institute for the History of Medicine in 1987, deal with the ways human senses are involved in medical diagnosis. Based mostly on British sources, they rely on primary printed and manuscript sources. The great strength of this symposium is not only that it avoids “presentism” -- interpretation or, worse, denigration of the past according to currently fashionable criteria -- but also that the authors, with few exceptions, get inside our predecessors' minds thoroughly enough that we can understand how diagnostic reasoning moved from observation and interrogation of patients to assessment of odors and subjective sensations, to percussion and auscultation, and most recently to quantitative, objective instrumental measurements.

In this book Vivian Nutton discusses Galen's bedside diagnostics and, probably correctly, regards the Hippocratic Epidemics as a collection of clinical case notes, although Liddell and Scott's Greek dictionary gives only a fourth-century a.d. provenance for epidemeuein as “to visit.” Elizabeth Sears bases her account of high medieval theories of sensory perception on traditional illuminated-manuscript illustrations.

Jerome Bylebyl addresses Giovanni Battista da Monte's clinical rounds in Padua in 1540 through 1551; da Monte stressed careful, methodical history taking and the notion that all five senses are involved in diagnosis -- not only the physician's senses, but the patient's as well. Diagnosis was then based on both a patient's narrative and answers and the physician's observation of the patient, but not a structured physical examination. Richard Palmer reviews the continuity from ancient to early modern theories of olfaction, discusses the role of smells in epidemiology, and illuminates the sometimes, to us, puzzling importance of aromatic herbs and perfumery in premodern materia medica.

Laurence Brockliss analyzes a controversy that arose between Galenists and Paracelsians in 17th-century Paris about whether observation by itself constitutes an autonomous basis for truth; the dispute had the unanticipated consequence of creating a strict division between popular and academic medicine. Martin Kemp has written a stunning review of anatomical illustration, raising questions about these teaching aids that still perplex those of us who teach morphology. He points out that different illustrators were selected because of their talent in various aspects of illustration and that anatomical illustration pressed available printing and engraving technology to its very limits.

Malcolm Nicolson, using hospital records, reviews the introduction of percussion and stethoscopy into early-19th-century Edinburgh, stressing that Laennec really wrote about morbid anatomy and that academic and practical knowledge differ. Time and experience are needed to train the senses when new diagnostic techniques are introduced and subtle sounds are added to more familiar methods of inspecting patients.

Susan C. Lawrence digests the lecture notes of 18th- and early-19th-century undergraduate medical students to document how uneasily words “reify experience”; incidentally, she provides extremely thoughtful advice for anyone who tries to interpret lecture notes, minutes, and reports from the past. She suggests that formal lectures provided both a rationale and a vocabulary for students' descriptions of what patients felt.

Roy Porter demonstrates that physical examinations, first routinely performed by supposedly less learned but anatomically oriented surgeons and male midwives, were met by the prejudice that such physical contacts were somehow indecent and liable to abuse. Gert Brieger contrasts Thomas Eakins's 1875 painting The Gross Clinic with his 1889 Agnew Clinic as a springboard for a meditation on changing popular perceptions of surgeons and surgery during the intervening 14 years of incredible progress in the field.

Merriley Borell has contributed an outstanding essay about the use of precision laboratory apparatus in preclinical training in late-19th-century medical schools. The availability of these instruments not only trained medical students to use quantitative measurements instead of qualitative assessments, but also led gradually to the replacement of anatomical by physiological reasoning as the focus of medicine changed from the patient to the disease process itself. Borell discusses the often overlooked importance of commercial manufacturers of standard and affordable measuring devices both in the acceptance of new forms of technology and in the replacement of clinical signs by graphic or numerical data. She perceptively concludes that the new techniques stressed investigation rather than reflection, that many new forms of technology were uncritically accepted, and that excellent technicians sometimes proved to be, in human terms, poor physicians.

Stanley J. Reiser summarizes how 19th-century physical diagnosis based on anatomy was replaced by the quantitative physiologic assessment of patients; technology was seen as objective, saved time because much measurement could be delegated to nonphysicians, and allowed standardized communication of results. He suggests that although skill in physical diagnosis has in fact declined in the United States, technical assessment of patients may be more accurate than hands-on approaches.

Overall, this is no collection of casual essays but serious historiography in the classical tradition of scrupulously detailed and documented textual interpretation. Reference libraries in the fine arts and general and medical history will want to have it.

William D. Sharpe, M.D.
Cabrini Medical Center, New York, NY 10003