- The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present by Roy Porter
HarperCollins, 833 pp, £24.99, February 1999, ISBN 0 00 637454 9
No one should take comfort from the title of Roy Porter’s shaggy masterpiece of a history of medicine. ‘The Greatest Benefit to Mankind’ – the phrase is Dr Johnson’s – begs for a question-mark, a rising inflection of incredulity, if not outright disbelief. Porter is too ebullient, too much of an optimist, too little of a polemicist to supply the Rousseauian rejoinder: ‘An art more pernicious to men than all the ills it pretends to cure’. But no one who follows Simon Schama’s advice helpfully prescribed in the blurb – ‘take a dose of the book at least once a day and retire early to bed’ – will sleep easy.
In fact, two narratives are here in constant tension. One is an up to date, deeply informed, but ultimately traditional, history of medicine, though mercifully short on the genealogy, on who begot whom, which gives much of the genre its familiar form of Biblical inevitability. Truth is firmly embedded in institutions, politics, economics, war, and does not spring virginally from the brilliant minds of doctors and their experiments. That said, one strand of this narrative is unashamedly triumphalist and teleological: ‘winner’s history’, giving more space to the Greeks than to the Goths, and to the father of Greek medicine than to Greek root-gatherers. ‘From Hippocrates to Biomedicine’ might be its working title: a world-historical tale of how ‘Western medicine’ broke with the ‘traditional wisdom of the body’ and became global. The scope and chronology of the first narrative are also more or less traditional: eighty pages take us from the end of antiquity, through the thousand years of early Christianity, the Middle Ages and Islam, plus several thousand years of China and India – until the real story resumes in the Renaissance. (To Porter’s credit, and as a testimony to his vast erudition, it is far more than one will find on these topics in other general histories.) A little more than a third of the way through – after a solid 59 pages on the Enlightenment – we are in the 19th century, when discoveries if not cures begin to pile up at an increasing pace.
In the age of Vesalius and Harvey, modernity and medicine begin their strange, ambiguously successful, pas de deux, as the body is mapped in ever finer detail, its deepest secrets are brought to light, and its ailments are chronicled, ameliorated and on occasion even conquered. Porter’s explanation of why ‘our’ medicine took off has to do with the emergence of a distinctive approach to the human body, in health and disease, which regards it as standing apart from nature and the cosmos. This in turn is part of the Western preoccupation with the individual and his identity, which is equated with, or reduced to, ‘the individual body and the embodied personality’. Western medicine is thus an almost paradigmatic form of modernity, a never-ending struggle against error, a constant revision of accepted methods and philosophical assumptions.
Medicine is the harbinger of secularisation. ‘I lift up mine eyes unto the pill,’ as Malcolm Muggeridge said archly; the Mayo Clinic, Porter in turn suggests, is one of the ‘cathedrals of the new medical science’: an almost too perfect exemplar of the metaphysical debilities of our time. We want more and more of what it seems to offer and are endlessly dissatisfied. Like all consumerism, but ‘more menacingly’, medical consumerism is designed to be unsatisfying. Doctors and the public are locked into a dialectic in which everyone has something wrong with them, a ‘something’ that can be fixed and fixed again. All-encompassing and linked in mass society to everything else, ‘medicine is the moving frontier, not simply of science and healing, but of the future of mankind.’ And so the Modernist dream of ever more knowledge and control over nature gives way to the desperate Post-Modern fantasy – or perhaps it isn’t a fantasy – that ‘everyone and everything can be cured.’
A dark ironic twist runs through the triumphalist narrative, however, and constitutes almost an alternative story. In the first place, Porter’s title is descriptive at best of the past 150 years of a 2500-year-long story, and arguably of only the past 60 or so. Before the middle of the 19th century, clinical medicine had almost no beneficent impact on health and may well have caused more harm than good; doctors at the Battles of Gettysburg or the Wilderness had no more to offer wounded soldiers – except perhaps opium – than did their predecessors in the Persian or Punic Wars. As late as the Twenties there were only four chemotherapeutic compounds. To be sure, major killers disappeared periodically but not through the agency of doctors or the power of science. Thus in medicine – unlike physics, chemistry or engineering – an immense accumulation of learning from the scientific revolution to our own century had almost no positive effect. One irony, among many, is that medicine became socially, politically and ideologically powerful quite independently of its efficacy in curing or even ameliorating diseases.
Then there is the psychological inverse of this. In the age of antibiotics, beta-blockers, insulin, hip replacement and so much more, on the doorstep of perhaps undreamt-of stem-cell therapies and even immortality – if those pesky telomeres which mark the time to the death of each cell can be reset – discontent is at a new height. From the Greeks to the Great War, Porter reminds us, medicine could do little: now, with its mission accomplished, ‘medicine’s triumphs are dissolving in disorientation.’ Inflated hopes lead to disappointment, the more unlimited the promise the more crushing its remaining unfulfilled.
Some of this is simply whining. Yes, longer life and successful management do give us more time to suffer the pains and debilities of old age but, as Woody Allen noted, consider the alternative. Still, Porter is on to something important here and the tension between his two narratives – the Exodus narrative of liberation from ignorance and disease, the other its ironic doppelgänger – suffuses his book.
The reason for the crisis of medicine, just when it seems to have come into its own, Porter argues, is historical, not just a symptom of the media’s preoccupation with lifestyle, which is true enough, though European readers are perhaps spared the worst excesses of contemporary health reporting. ‘It’s Man v. Microbe and we are losing,’ warned an advertisement in the New York Times as I sat down to write this review: ‘Ebola’, ‘Lyme Disease’, ‘Aids’, ‘Tuberculosis’ in grey, misty typeface float out a murky background like invading monsters from deep space. As an alternative, there is the mindless good cheer that can only lead to tears: ‘Prostate Cancer: A Journey of Hope’, Public Television promises. I can hardly wait. And every Tuesday the ‘Science Times’ invites readers to embrace or reject yet another food or beverage so as to prevent this cancer or that form of heart disease.
In the beginning, Porter reminds us, there was disease: pathogenic organisms, animals and humans in unstable imbalance. And with the Greeks we began to try to do something about it. Their philosophical breakthrough, he suggests, was to position medicine as part of the problem of the nature of reality and of change. Health, according to Hippocrates, was equilibrium; ill health its opposite: understanding disease meant understanding the balance between man as a corporeal being and his surroundings. Among the Greeks medicine was personal and it remained so among the Romans. A doctor attended a specific patient; he was not an intermediary to the gods nor was he a magician, although Porter is careful to point out that this rationalistic account of health and disease, physician and body has had to co-exist with all sorts of popular belief right up to the present. The difference between primitive and civilised can be more illusory than real.
The cultural legacy of the Greeks and their successors was extraordinary. The Hippocratic ideal is still resonant in Western medicine; Galen of Pergamon, the greatest by far of the Roman doctors (he wrote in Greek), was a towering presence for nearly two millennia. Even after mechanical philosophy shattered the philosophical foundations of his medical theory in the 17th century, Galenic therapy lived on for roughly two more centuries. Bleeding, purging, heating and cooling survived even if humorialism was in a shambles.
If, however, Porter believes – as his chapter on antiquity seems to suggest he does – that there is some specific telos at work here, some more or less discernible philosophical path from Athens, Cos or Pergamon to modern biomedicine, he is stretching the evidence. Indeed, as he himself suggests later on, Chinese medicine after the Shang, like its classical Western counterpart, was humorial; it hinged on the constitution of bodies. I am not sure he is right that the five Chinese elements were any less ‘physical’ than their four Greek counterparts. And the Chinese notion of qi or ‘vital breath’ is, if anything, more personal – more a quality of this or that patient – than a vaguely comparable classical concept like pneuma, the ‘breath of life’. As for therapy and prevention, there was no clear winner at the starting line. The Chinese had smallpox inoculation well before the West and a gentler basic clinical practice. Most of us would prefer moxibustion to bloodletting and if one had had the choice in the second century BCE where to fall ill, one might well have picked the East.
Chinese medicine was perhaps not given to novelty and innovation, but, for a couple of millennia, neither was its Western counterpart. The first priority of the great medical humanists of the Renaissance, as for lay scholars, was to recover Greek texts. Europe’s leading printing press published a landmark Greek edition of Galen in 1525, and 590 editions of various Galenic works appeared in the succeeding 75 years. Hippocrates was translated into Latin. (The great modern edition appeared in 19th-century Paris.) In an age like ours, when few doctors read papers more than ten years old, and a five-year-old textbook is obsolete, the longevity of Greek medicine is astounding.
Yet Chinese medicine did not become global medicine and it is outside Porter’s brief to explain why. Suffice it to say that within a century of the eunuch admiral Zheng He’s decision to turn back his magnificent fleet – immeasurably grander and technologically more advanced than anything the princes of Europe could hope to launch – and not to proceed around the Horn of Africa, Andreas Vesalius, teacher of anatomy in Padua, had published De humani corporis fabrica, that monument to the conviction that ‘the violation of the body would be the revelation of its truth.’ There he stands insouciantly before Death on the Fabrica’s frontispiece. No text better ‘presents the dreams, the programme, the agenda, of the new medicine’. If there is a year zero for biomedicine it is 1543 and little wonder that today the ritual introduction to medical education is still dissection. That first cut into the great muscles of the back is as epochal a rite of passage as any we know.