May 17, 1998
In The Problem of Pain C. S. Lewis invited his readers to “lay down this book and reflect for five minutes” on life in “a world without chloroform.” Thirty seconds was about all I could stand, but it was a useful exercise: good for the soul, and good preparation for reading Roy Porter’s immense new “medical history of humanity.”
For anyone but Porter, it might be a foolhardy ambition. Even this professor of the social history of medicine at London’s Wellcome Institute for the History of Science, editor of the Norton History of Science series, and author of A Social History of Madness, London: A Social History and many other books, can’t make it look (or read) easy. But The Greatest Benefit to Mankind (the phrase is Samuel Johnson’s) is a remarkable achievement: for the most part, it is brisk without being breathless, comprehensive without being tedious, rigorous without being obscure, judicious without being jejune. The subject is, of course, impossibly vast and vexed; but few imaginable topics aren’t at least touched on, few relevant questions at least glanced at.
Medical practice is as old as civilization, but medical science began with the Greeks. Everywhere else in the ancient world, disease was thought to have supernatural causes and treatment was accordingly magical. Hippocrates decisively separated medicine from religion, linking it instead with philosophical and (proto-) scientific speculation. Equally important, Greek democracy freed physicians from state control and permitted medical controversy.
This was a noble beginning, but despite isolated discoveries and therapeutic successes by Arabic, Indian, and Chinese thinkers and healers (and a few Europeans, like Vesalius and Paracelsus), the systematic growth of medical knowledge had to wait for the seventeenth-century scientific revolution. As dissection became more common, laboratory instruments were perfected, and the vernacular languages displaced Latin, medicine came to be based less on scholastic disputation about ancient texts and more on experiment and observation. In particular, with Harvey’s theory of circulation and Leeuwenhoek’s development of the microscope, anatomy and physiology took off.
The late nineteenth century was the heroic age of medical research. Pasteur, Koch, and other giants mounted an assault on the infectious diseases: tuberculosis, cholera, diphtheria, typhoid, tetanus, meningitis, rabies, syphilis, gonorrhea, leprosy, and others. “In the twenty-one golden years between 1879 and 1900, the micro-organisms responsible for major diseases were being discovered at the phenomenal rate of one a year.” The antiseptic theories of Lister and Semmelweis sharply lowered surgical mortality rates. Roentgen, Becquerel, and the Curies founded radiology.
But medical practice lagged far behind. Discoveries in the laboratory did not always or immediately lead to effective therapies. Porter is at pains to emphasize the immemorial helplessness of patients and doctors before sickness and death. At the outset of the medical enterprise, Hippocrates had warned his students: “Life is short, the art long, opportunity fleeting, experience fallacious, judgment difficult.” Twenty-five hundred years later, an American physician recalled in his autobiography: “I can scarcely think of a single disease that the doctors actually cured during those early years [i.e., of the twentieth century].” All they could do was “relieve suffering, set up bones, sew up cuts, and open boils on small boys.”
From the perspective of public health, the record is even more chastening: a steady procession of incomprehensible catastrophies. Chronicling these large-scale, impersonal phenomena -- the plague and the pox, epidemics and pandemics, the devastation of New World populations by European diseases, the horrors of nineteenth-century cities, the profligate morbidity of modern war -- Porter’s gifts as a social historian come most fully into play. The rhythms of his prose accelerate, the colors intensify, the statistics take on a macabre poetry. Literary references -- Heine on mob frenzy during a Paris epidemic, Engels on the back streets of industrial Manchester, Maupassant on the psychological compensations of syphilis -- are abundant and graphic.
In the twentieth century, medicine has shifted from being mainly palliative to being, frequently at least, curative, and occasionally even preventive. Smallpox, tuberculosis, cholera, malaria, and other communicable diseases have yielded to penicillin, antibiotics, and sulfa drugs (though many of them have made a comeback, as their micro-organisms mutate into resistant “superbugs”). Dietary and lifestyle changes have slashed coronary fatalities in half over a single generation; smoking is way down, and lung cancer rates will eventually follow. Surgery is, technologically speaking, a brave new world. Porter cautions, sensibly enough, that “no more than there is a free lunch is there such a thing as an unalloyed medical breakkthrough.” Yet it’s impossible not to be impressed -- even, on occasion, thrilled -- by the intellectual achievements he recounts and to feel a little dizzied by vistas of future progress.
Politics brings one down to earth. As Porter emphasizes throughout, what is usually responsible for medical progress is “not a therapeutic breakthrough but a healthier environment and improving patient resistance” -- in other words, better conditions of life. A century and a half ago, when Victorian public-health reformers commenced their great work, virtually no one who was comfortably off knew or cared how the poor lived and died. The reformers appealed successfully to Christian piety and bourgeois prudence, and the age of social (ultimately, socialized) medicine began in Europe. The two world wars convinced many other governments (including our own) to invest in public health, if only to improve the quality of their cannon fodder. At the end of the twentieth century, things are better, at least rhetorically. There’s UNICEF and the World Health Organization and scores of other international institutions.
But as Porter acknowledges, “the basic health of the developing world is deteriorating.” Water purification, vaccines, plumbing, and mosquito nets -- not to mention all that food American farmers are paid not to grow -- would save tens of millions of lives each year and dramatically improve hundreds of millions of others. Even in the developed world, medicine is not for everyone. One in five Americans either has no health insurance or has so little that a major illness would lead to bankruptcy. For all the miracles and all the heroics with which The Greatest Benefit to Mankind teems, “what medicine will achieve practically for humanity, and what those who hold the power will allow it to do,” Porter concludes warily, “remain open questions.”