The Way of All Flesh

Roy Porter is a phenomenon. Among general readers on this side of the Atlantic, he is perhaps best known for his learned and dazzlingly entertaining history of London, and for his rich and rollicking social history of England in the 18th century. British audiences encounter him in a variety of other guises: as an astonishingly prolific reviewer of books on all manner of subjects and as a ubiquitous presence on television and radio, wittily discoursing on any number of historical themes. Scholars, however, are aware that these manifestations are only the tip of a very large iceberg: For them, Porter looms as an author and editor of positively Stakhanovite proportions, a veritable one-man publishing industry.

Editor for many years of major journals in both the history of psychiatry and the history of science and of scores of books and major works of scholarly reference, he is also the author of more than a dozen well-received, specialized monographs on topics ranging from the history of geology to the history of sex; from the Enlightenment’s deification of rationality to the history of madness and unreason; and from quackery and “the sick trade” in 18th century England to a biography of another famous scribbler, Edward Gibbon. Only someone possessed of prodigious powers of assimilation and synthesis (to say nothing of preternatural intellectual talents and curiosity) would have been tempted to range so widely--not the least because these are territories populated by hosts of jealous academic specialists, each small sect ill-disposed to trespassers from outside their own narrow little guild.

Porter’s latest book demonstrates anew his daring and his erudition. Indeed, “Benefit to Mankind” is in some respects even more ambitious than anything else he has written to date, aspiring to provide nothing less than “a medical history of mankind” from hunter-gatherer societies to high-tech Western medicine at the dawn of the new millennium, and everything in between. In almost all relevant respects, it must be accounted a triumph: simultaneously entertaining and instructive, witty and thought-provoking, a coherent overview comprising within its 832 pages an elegant and moving set of reflections on our collective efforts to grapple with disease and debility and to come to terms with the frailties of our flesh.

In undertaking this Promethean task, Porter has clearly benefited from his position as a professor at the foremost center for medical-historical scholarship in the world, the Wellcome Institute for the History of Medicine in London (an establishment founded, appropriately enough, on the fortune of Sir Henry Wellcome, one of the great pharmaceutical entrepreneurs of the early 20th century). Assured of access to the treasures of the institute’s library and, equally important, to the array of scholarly expertise on its staff, Porter has been able to work in an enviable scholarly setting. But it is what he has made of those material riches and intellectual advantages that matters to the reader, and what he has produced is without question the best single treatment of the subject we have or are likely to have in the foreseeable future.

Corresponding to the prejudices of our age, Porter’s treatment of his subject avoids possible charges of ethnocentrism or elitism and makes a virtue of refraining from making anachronistic judgments about the people and procedures it examines. Porter insists that he comes “not to praise medicine--nor indeed to blame it” and urges us, quite rightly, to see that “the prominence of medicine has lain only in small measure in its ability to make the sick well.” Within his narrative, East and West, allopathic and homeopathic, the subterranean reservoirs of medical folklore and the promise of molecular medicine, Stone Age and New Age, yin and yang, male and female, all find their place on the stage, and all are placed within the frame of wider religious, philosophical, scientific and political beliefs.

There are, of course, limits to Porter’s ambition. “The Greatest Benefit to Mankind” places medical thinking and medical practice at center stage so that topics such as folk beliefs and practices or the demography and epidemiology of disease, important in their own right and accorded a measure of attention, are nonetheless not its primary focus. But the formal and written medicines of the Middle East and of Egypt, of China and of India, of Islam and of Greece and Rome are the recipients of respectful and sustained attention, and the survival of alternative and holistic medicines in our own, supposedly rational-scientific age also pass in review.

Readers interested in how Muslim physicians established sizable hospitals as early as the 9th century and kept Greek and Latin medicine alive through the Dark Ages in Western Europe; or concerned about the uses of herbs and therapeutic massage in traditional Indian medicine; or perhaps intrigued by the place of acupuncture within the vast corpus of Chinese medicine, will find their concerns addressed at more than passing length. Still, the bulk of the book fixes its attention elsewhere, on “what began as the medicine of Europe [but] is becoming the medicine of humanity.”

The radically distinctive character of Western medicine and its evolution from the Renaissance onward constitute the subject matter of perhaps two-thirds of the text. Porter is no prisoner of the post-modern relativism that would deny the very notion of scientific and medical progress, but neither is he an uncritical cheerleader for the miracles of modern medicine. On the contrary, he rightly points out its limits: how little, in some senses, even the most technologically sophisticated medicine weighs in the balance of health; how disproportionate our investment is in forms of medicine “whose benefits come late, which buy a little time, and which are easily nullified by external, countervailing factors.”

He acknowledges the victories of scientific medicine over infectious diseases, the capacities of modern surgery to alleviate suffering and to allow the lame to walk and even (sometimes) the blind to see, and the promise of molecular and genetic medicine (though reminding us that this particular promissory note still remains mostly unpaid). But such accomplishments and potential should not, he suggests, lead us to overlook the limits of curative, interventionist medicine and its quite “modest part in shaping wider morbidity and mortality patterns within the community.”

Although both Eastern and Western medical traditions had once shared common assumptions about the balanced and natural operations of the healthy body, Western medicine in the 16th century moved toward a radical break with this tradition as new knowledge and power flowed from the growing emphasis on anatomy and on the investigations of the workings of the body that the anatomical approach increasingly opened up. It took centuries before growing scientific understanding translated into interventions that made a demonstrable difference in people’s lives, but developments in the period from 1500 to 1900, both intellectual and professional, make for fascinating reading.

It would be easy for a narrative of this sort to degenerate into an arid series of accomplishments and of one heroic figure following another, a tedious recital that would perhaps give some sense of the evolution of science, therapeutics and bedside care, but one that would numb rather than stimulate the reader.

Instead, the story proceeds with vim and vigor. Porter moves easily and authoritatively from one national context to another, from morgue to laboratory to bedside, from home to hospital to the political arena, providing a well-shaped and remarkably thorough overview of the evolution of medical science, medical practice and patient care from the early modern era to the present.

A crucial moment, for example, came with the invention of the stethoscope by the Parisian physician Rene Laennec in 1816. Examining a rather stout young woman with symptoms of heart disease, he was inhibited from checking his diagnosis through the then-standard technique of direct application of his ear to her chest because of the patient’s age and sex. In an instant of inspiration, he employed a tightly rolled sheet of paper as an intermediary and heard the heartbeat more clearly than he ever had hitherto. As he immediately grasped, here was the key for “studying, not only the beating of the heart, but likewise all movements capable of producing sound in the thoracic cavity.” More momentous still, “by bypassing the patient’s unreliable account, diagnosis could be rendered objective.”

Though English examples are drawn upon somewhat disproportionately, one nevertheless gains a nuanced and sophisticated sense of the general patterns of development on all fronts: science, practice and patient care. But the general is always neatly integrated with the particular, and ideas and individuals are carefully placed in context and made human. Moreover, the sheer range of materials drawn upon, apparently effortlessly, commands one’s admiration. Novels, letters and plays take their place alongside medical texts and the physical artifacts and sites of medical intervention, all woven into a seamless tale that draws the reader and provides a vivid portrait of our predecessors’ (and our own) struggles with pain and disease, debility and death.

It helps, of course, that Porter’s prose is always engaging and frequently memorable. Medicine, he shows, was frequently misogynistic: “Women were leaky vessels (menstruating, crying, lactating), and menstruation was polluting.” Surveying the impact of a new understanding of scurvy, he pithily sums things up in a couple of sentences: “Lemons perhaps did as much as Nelson to defeat Napoleon. (Later the less effective limes were used, giving rise to the identification of the English abroad as ‘limeys.’)” Or there is his assessment of the skills of Sir Henry Halford (1766-1844), physician to four English monarchs: “So suave was his bedside manner that aristocratic women were said to prefer dying with Sir Henry than living with lesser physicians.” A sharp contrast, it would seem, with his contemporary, the surgeon Robert Liston (1794-1847): “[A] lion of a man with a sharp knife and a sharper temper. Speed was his forte, biting the blade between his teeth like a butcher so as to free his hands and save time.” Moving from personalities to procedures, and looking at pictures of the preanesthetic era, he dryly comments in one caption about one of the many engravings and photographs that enrich the text: “Early illustrations of amputation are commonly stylized and comfortingly suggest a serenity in the patient and a gentleness in the surgeon which actual operating conditions must have belied.”

But beyond the elegant or memorable turns of phrase, the realities that Porter is discussing have their own intrinsic fascination. The evolution of surgery, for example, from a low status trade from the time of the Greeks (not least for its stress of hand over head) to today’s triumphs of technique and curative capacity, is itself a remarkably compelling story. Porter quotes a chilling description by the novelist Fanny Burney of the progress of her mastectomy, a macabre ritual undertaken sans anesthetic. He surveys the mountebanks and charlatans who helped usher in the era of anesthesia and lays bare the peculiarities and limitations of Joseph Lister, the founder of anesthetic surgery and the first English doctor to become a lord. Lister, for example, operated in his street clothes, and he made the odd claims that abscesses were germ-free and staphylococci and streptococci were ubiquitous and often nonpathogenic.

On another front, recounting the origins of the bacteriological revolution, Porter displays Pasteur as scientist and showman and shows how his German rival, Robert Koch, “outpasteurized” Pasteur by staging a dramatic Christmas rescue of a child with the first injection of diphtheria antitoxin. Yet the sainted Koch, discoverer of the bacilli causing both tuberculosis and cholera and codifier of the ground rules for proving the etiological relationship between germ and disease, is also shown in a rather different light: He devised what he purported to be a secret remedy for TB, then sold the useless, even dangerous, “tuberculin” for a small fortune to finance his divorce and remarriage, decamping to Egypt with both the proceeds and his young bride. Even the heroes of medical advance (shades of modern scandals over the discovery of HIV) sometimes have feet of clay.

Porter closes his account with some musings on a peculiar paradox of our age: “[N]ever has [medicine] achieved so much or attracted such great suspicion.” In many ways, he suggests, Western medicine has become the prisoner of its own success, hostage to the impossibly rising expectations which its therapeutic breakthroughs have engendered, and seems tempted to expand its claims by “medicalizing normal events . . . converting risks into diseases, and treating trivial complaints with fancy procedures.” Worse still, there is the danger that its future may involve the expenditure of larger and larger sums of money to secure “meagre increments of unenjoyed life.” Grim prospect indeed, and a depressing note on which to end a splendid and thoroughly engrossing book.