Even Immortality

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.

No surface, no depth of the earth is proportionately so dense with the names of its eponymous explorers as the human body. Over four centuries its every structure – large and small – was the object of exposure, probing, knowing and occasionally even controlling. Their names are everywhere: the Fallopian tubes and Eustachian tubes, after two of Vesalius’ more distinguished successors; Bartholin’s duct and the duct of Wirsung; the Graafian follicle; Tulp’s valve (after Dr Nicolaas, the central figure in Rembrandt’s Anatomy Lesson); the circle of Willis at the base of the brain; the Islets of Langerhans in the pancreas; Broca’s gyrus; Buck’s fascia; the loop of Henle filtering in the kidneys; the bundle of His conducting electrical impulses in the heart; the angle of Louis telling generations of medical students where on the chest to place their stethoscopes. There are scores of named physiological processes – Babinski’s sign, the Pavlovian conditioned reflex, Cheyne-Stokes breathing – and even more diseases: Bright’s, Addison’s and Hodgkin’s for the ‘great men of Guy’s’ who in the early 19th century absorbed the traditions of Paris medicine and described, respectively, the diseases of the kidney, adrenal glands and lymphatic system for which we still remember them.

Neurology seems especially rich in eponyms perhaps because for so long the discipline could do little more than describe the ravages of the nervous system: Huntington’s chorea, one of the first diseases whose genetic causes were discovered in the early Nineties – after the obscure upstate New York doctor, George Sumner Huntington, who specified its symptoms in 1872; Parkinson (James) got his tremor in 1817 and soon thereafter the great anatomist Charles Bell, whom Darwin admired, could be even more precise about ‘his’ disorder – Bell’s palsy – of the seventh cranial nerve; Alzheimer’s disease after Alois of early 20th-century Munich; Gilles de la Tourette’s impulsive tics and Korsakoff’s (Sergei, that is) amnesia, both recently made famous again by Oliver Sacks; Creutzfeld-Jacob disease, just to bring us right up to the mad cow. (No woman – at least at this level – seems to have had anything named after her.)

A name announces only the dénouement, however: it does not convey the extraordinary labour, often the bravery, intelligence and observational and strategic brilliance that its attachment to some part, process, procedure or disease celebrates. And many explorers of the body did not leave eponyms. Porter tells the well and less well known stories with a boundless vigour and restrained economy that manages to convey both the sheer cumulative magnitude of achievement and how painfully, piece by piece, it was assembled.

Where to start? By the late 17th century, Galenic theories of digestion had fallen to men like Gaspare Aselli, who opened up a recently fed dog to discover that the chyliferous vessels of the intestine had become swollen with a milky fluid in response to food; his successors went on to discover the pancreatic duct (that’s Wirsung’s) and the submaxillary and parotid glands. Building on another century’s worth of thinking and research, the French naturalist René Réaumur trains a kite to swallow and regurgitate small porous tubes of food, to discover the role of gastric juices; and Spallanzani – who also did important work on parthenogenesis in tadpoles and on the role of sperm – swallowed and regurgitated little bags of food himself to establish the solvent power of saliva. ‘Thanks to a bizarre stroke of luck’ – one is tempted to ask whose – an American Army surgeon spent a lifetime on these problems. He managed to sew up a trapper with a gunshot wound to the stomach: fortunately for the doctor, not so fortunately perhaps for poor 19-year-old Alexis St Martin, a fistula remained which had to be plugged to keep food in, but which also provided an unexcelled window into what happened to food once it disappeared down the throat. So, in what a standard account calls one of the most romantic episodes in the history of medicine, the young man was taken from the woods to New York, where for decades his doctor could watch exactly what went on in his stomach when he ate.

Some of this is real ‘north face of the Eiger’ stuff. Jesse Lazear let a mosquito bite a yellow-fever victim and then munch on his own arm; the now standard diagnostic heart catheterisation was first done by a 25-year-old German medical student, Werner Forssmann, on himself. Two years later, he created a sensation by doing it again, but this time injecting himself with dye and having himself X-rayed.

Many more of Porter’s tales are of hard work, sheer brilliance, or both. On a hot and overcast day – 20 August 1897 – in Secunderabad, Ronald Ross dissects the stomach of his last Anopheles mosquito from a batch of seven which had bitten malaria-sufferers. His eyes are tired, he fiddles with his microscope and is rewarded by finding the eggs of the parasitic organism which causes one of the world’s great killer diseases: ‘Mosquito Day’. Or William Castle (1897-1990), a young resident at Boston City Hospital who knew from earlier work that pernicious anaemia involved the production of too few red blood cells, that vast quantities of raw or slightly cooked liver resolved the problem, and that sufferers from this disease had very little hydrochloric acid in their stomach juices. The question remained, however, why such large quantities of liver were required and what, if anything, the abnormal stomach secretion had to do with it. Castle’s hypothesis was that there was something lacking in the gastric secretions of people who had this anaemia, which meant that they had to process vastly more of whatever was present in liver to get what a healthy person derived from a regular diet. So he fed patients who had the disease a relatively small quantity of minced rare steak for ten days. No improvement. Then he fed them by stomach tube rare steak that had been eaten by healthy people and recovered from their gastric contents – i.e. meat already in part digested. Within six days the patients’ blood showed signs of improvement. Then he tried transferring only the stomach juices of the healthy people to the sick ones. No effect. QED. There was both an intrinsic factor which the secretions of people with pernicious anaemia lacked and an extrinsic factor, something which meat provided but, in the absence of the intrinsic factor, only when given in great quantities. (Subsequently, it was learned that what was missing was vitamin B12 and that the abnormal stomach juices lacked a substance required for its transport.) Porter offers hundreds of pages of such ‘great doc’ stories – uniformly fascinating even if they sometimes come in torrents; and he makes it clear that great minds do not work in institutional isolation. The net effect, however, is to leave the reader awed at the Himalayan scale of medicine as an intellectual but also a social enterprise.

Only institutions of the size of the 19th-century Paris hospitals and their imitators could provide the ‘material’ for the clinical-pathological correlations which were the foundation of the new medicine. As Marie François Xavier Bichat, one of its founding masters proclaimed, one can spend twenty years sitting at bedsides, but start cutting into bodies ‘and obscurity will soon disappear’. Rokitansky, in Vienna, is said to have done 60,000 autopsies during his career. (I had always heard 25,000 – Beethoven among them – but on such a scale who’s counting?)

Meanwhile, at the level of basic research, the post-Napoleonic German universities – imitated later in the United States and elsewhere – became veritable factories of knowledge, producing generation after generation of medical scientists, journal editors and academic clinicians, right up to their destruction by National Socialism. (Fifteen thousand Americans had studied in Germany by 1914.) Justus von Liebig’s Institute for Chemistry at Giessen, and later in Munich, revolutionised the study of how the body produces energy and taught his techniques to whole cadres of zealous students; his contemporary, Johannes Müller, the professor of physiology and anatomy at Bonn and then Berlin, did basic research on the way sensory nerves work, wrote the century’s leading physiology textbook, founded Europe’s major journal in the field and a dynasty which produced mountains of experimental validation for the proposition that the body was nothing more than a complex system of measurable physical processes. Robert Koch’s Institute in Berlin was the epicentre for the bacteriological revolution – one pathogen, one disease and, we hope, one vaccine, one cure – which still dominates medical thinking. And so on. By the end of the 19th century the institutional infrastructure for biomedicine as we know it was firmly in place and had performed brilliantly in elucidating the secrets of life. But not in prolonging it, or easing its pains.

So a question-mark haunts Porter’s title. In the first place, this history of medicine and perforce all histories of medicine – perhaps even the discipline itself – are sailing under false colours. A ‘history of medical thinking and medical practice’, yes; a history of ‘healers’ in the broad sense, no – at least not on the evidence presented here. There is – or there had been until sometime between 1900 and the early Forties – a radical disjuncture between what we know and what difference it makes. One might take the discovery of insulin in 1922 as the moment at which medical science came into its therapeutic own. (It also produced the first of the notorious Nobel injustices: Charles Best did not get the Prize; John Macleod, who was off fishing in Scotland during the crucial experiments, did.) Or penicillin. Anne Miller, the first patient to be saved by the antibiotic, died on 27 May this year at the age of 90. Her hospital chart from 1942, showing the dramatic break in her life-threatening fever, is preserved in the Smithsonian. Insofar as medicine heals, it started doing so within the lifetimes of many of us. Making people physically better has not loomed large in its history.

In the late 17th century, almost 150 years after Vesalius and the beginning of bio-medicine, the great physician Thomas Sydenham observed that he knew old market women in Covent Garden who understood botany better than medical students did. Until the discovery of antibiotics, the same old women could probably prescribe as well as the most learned doctor. Huge advances in looking, a radical rethinking of the body, whole libraries of new knowledge had done nothing to halt the plagues that continued to ravage Europe, the mad were just as miserable, and everyday pain was in no way diminished. A century later, Jean Nicholas Corvisart, a pioneer in correlating heart sounds and heart pathology, put it succinctly: ‘medicine is not about the art of curing people.’ A century after that – we are now in 1901 – Frederick Gates, the Baptist minister who was John D. Rockefeller’s chief adviser, was shocked to discover on reading the great William Osler’s medical textbook, how few diseases could be treated, much less cured.

In the relatively few instances in which doctors were of ‘benefit to mankind’ the relation between medicine as a discipline and its benefit is complex. By giving sailors lemon juice James Lind did prevent those lucky enough to come under his care from developing what we know as scurvy. But this was not because he understood, however imperfectly, that the sailors lacked something in their diets – i.e. because he had the idea of a deficiency disease (this would have to wait until the 20th century). Like some lay people, he was an advocate of cleanliness and thought that lemon juice was a detergent that would open pores and allow proper perspiration in moist climates.

Smallpox vaccination seems to be one of the few pre-20th-century bright spots but it, too, bears little relationship to basic research. In Britain at least, the disease was probably waning on its own. Moreover, the quota of deaths which vaccination did prevent was quickly filled by other killers, waiting to occupy the vacant ecological niche. Total mortality was little if at all affected. The practice of vaccination in fact came to England from the folk-healers of the Ottoman Empire, via Lady Mary Wortley Montagu, and Edward Jenner himself credited it as common knowledge among farm people that those who had had cowpox could safely nurse those ill from smallpox, and that those who had had smallpox did not get cowpox. And while his having learnt from folk wisdom does not detract from Jenner’s achievement, it does point yet again to the tenuous relationship between medicine as a system of knowledge and as a contender for ‘the greatest benefit to mankind’.

Of course in the 20th century, and especially since the Second World War, basic science has had considerably more impact on the development of drugs, vaccines and diagnostic procedures of all sorts. But for all the triumphs of biomedicine, its record is complicated. We know vastly more about malaria than ever before, but the world’s prime killer claims three times more lives now than it did four decades ago. The war on cancer is at a stalemate after merciful early triumphs against some of its forms – childhood leukaemias and testicular cancer, for example.

One would have to be a fool not to be grateful for much of modern medicine, both in saving lives and in saving us from the debilitating but not fatal illnesses that plagued our forebears and their children: Pepys’s weeks of blocked bowel, Goethe’s chronic tonsillitis, Monet’s failing sight, which today would only need a 20-minute cataract operation to restore to something better than before, and so on, endlessly. No parent who has watched a child’s earache vanish before the power of amoxycillin can be other than happy to be living in the antibiotic age. But such moments should not blind us to the fact that the disjunction between knowing and doing has been enormous and remains so even now. Physics and chemistry drove two industrial revolutions before medical science did much of anything. Perhaps it is some inarticulate understanding of this historical fact that lies at the core of contemporary discomfort with biomedicine. But that discomfort has other causes as well.

It may be a good thing for research that ‘the sick person has become a thing,’ as the 19th-century German physician Robert Volz observed; it may even be good for the patient to be treated ‘objectively’. But most of us want to be treated as human beings when we are sick and it is remarkable that a history of caring is almost entirely absent from this and other histories of medicine. It just isn’t part of the story. Out of 718 pages of text, Porter devotes slightly more than five to nursing in all its aspects, which is all the more remarkable given that Florence Nightingale’s famous intervention at Scutari – simply cleaning up the place – caused mortality to drop from 42 per cent to 2 per cent, the most dramatically successful intervention he records for the entire century. Similar results were attained when American Civil War hospitals were cleaned up. As Porter does repeatedly show, clean air, clean surroundings and especially clean water did more to reduce sickness and death than any medical interventions ever.

In addition to operating the gears and wheels of the gigantic engine that is contemporary hospital medicine, nurses also make the ministrations of that less than gentle machine bearable to its patients. It is all very well to decide on a course of chemotherapy and to monitor it on a day to day basis – the role of the oncologist – but a patient survives such a massive assault only because someone cares, in an intellectually not terribly thrilling way, for the ordinary needs of the body: cares that liquids are taken in and wastes eliminated, that the skin remains intact and its surfaces more or less clean.

Porter alludes to these issues indirectly in his almost Blakean attention to the inhuman scale of medicine and to the ever-dimming hope of personal care. A big London hospital in 1800 might have done a couple of hundred operations a year: the Mayo Clinic in 1924 did almost 24,000 with nearly 400 doctors and 900 other workers in its employ. Of course, 20th-century surgery is infinitely superior to its cottage-industry version, but medicine, Porter writes, has turned into a ‘juggernaut’, and his history, rather like an anti-industrial novel, laments the demise of the small-scale and intimate: 146,500 hospital admissions in the US in 1873, 29 million a year in the Sixties. ‘Who killed cock robin?’ one of his sources asks: who killed the primary-care doctor whose job it was to provide individual solace?

Again, the division of labour that characterises industrial-style medicine has its virtues. Specialisation pays. The greatest ‘cutter for stone’ in the 19th century was a quack named Frère Jacques and today the most successful hernia surgeons are in clinics which do nothing but repair inguinal breaks. But Porter is not alone in pointing to the irony that efficacy seems to have been bought at the price of humanity.

He says that he intended to write a history of doctors, not diseases. But malaria and yellow fever, syphilis and gonorrhoea, plague, smallpox, cholera, typhoid and typhus, influenza, cancer, heart disease, Aids, measles, madness stride across the landscape like unruly giants, coming and going as they please. Medicine looks rather puny by comparison. The Black Death appears in Europe in the winter of 1347, periodically devastates its population for almost four hundred years and, after one last outbreak in early 18th-century Marseille, forsakes the continent. Why this was so is much debated but no one credits the doctors. Columbus and those who followed him to the New World brought with them a catastrophic array of new micro-organisms which killed up to 90 per cent of the population. Nothing to be done. Explorers and merchants spread tropical disease from localised hubs through vast new regions of Africa, and tropical medicine, supposedly the saving grace of colonialism, probably did more harm than good until very recently. Again ironically, one of the few effective 19th-century medicines – quinine – made it possible for white men to swarm over West Africa, bringing still more micro-organisms and death in their wake. The practice of slavery introduced yellow fever from Africa to the Americas in 1647. The origin of syphilis is a hotly contested question but it appeared in Europe as an acute, deadly disease in 1494, following almost immediately on Columbus’s first voyage. Pathogens then and now travel on itineraries not previously cleared with doctors, moving uninvited whenever we move.

World war brought world pandemic: twenty million dead from influenza in 1919-20, more than the number killed by the guns. Typhus-carrying lice killed three million in Russia between 1917 and 1921 and elicited Lenin’s famous remark that if socialism did not defeat the louse, the louse would defeat socialism. And when the big infectious diseases did retreat, it was not because of what doctors did, but because of the largely unsung builders of sewers and water systems, the makers of soap and pavers of streets. However credit is apportioned, the historical record is perfectly clear: death is a social disease – this was among the many discoveries of early 19th-century French doctor/statisticians and is supported by modern demographers. When social conditions improved, so did health and lifespan. Tuberculosis began its disappearing act long before Koch discovered its cause and even longer before antibiotics made it treatable. So did typhoid and cholera. Born of dirt and poverty, these and other infectious diseases declined as the worst effects of industrialisation and urbanism were attenuated; they survive today in places too poor or mismanaged or disrupted by war to keep clean.

More immediately disturbing is the persistent ground bass of violence in counterpoint with logarithmic increases in knowledge and clinical efficacy. No Hippocratic maxim has been more honoured in the breach than ‘First do no harm.’ One might ignore the occasional hyper-energetic treatment of a dying monarch by physicians anxious to be seen to have tried everything: Charles II was bled of 16 ounces, then cupped around deep cuts in his shoulders to relieve him of another 8; he was given antimony as an emetic to swallow and purgatives by mouth and by anal clyster; his head was shorn, blistered and cauterised. Death intervened to save him from his doctors.

One might look the other way at the bloodletting perpetrated well into the 19th century, even (or especially) by leaders of the profession, despite growing evidence that it did no good. After all, systematic studies of efficacy did not become standard until after the Second World War. Still, the rivulets of blood amounted to a torrent. France imported 33 million leeches in 1837; and of course blood was drained in other ways as well. (A leech grows from 3.75 cm to 15 cm: assuming a constant diameter of 1.5 cm – the leech also gets fatter – that works out at nearly 1.3 million litres of blood per annum drained by these little annelid worms of foreign origin.) One might even discount the evidence which Porter cites from Medical Nemesis by Ivan Illich, which argues that much illness today is iatrogenic – caused, in other words, by doctors and hospitals. But Illich’s longing for a better day, when pain had spiritual meaning, makes one suspicious. Recent data showing that 100,000 people die in America as a result of medical error are difficult to interpret: many might have died of their illnesses anyway.

Yet there is something about the core doxa and guiding therapeutic principle of the medical tradition that Porter traces – that disease is the product of something specifically wrong with a specific body; that health will follow on its removal – which perpetuates violence. To be sure, doctrine and principle also guide a massive and successful research tradition but therein lie the ironies pervading this history. The patient and healer look benign enough in Isaac Koedijck’s painting A Barber Surgeon Tending a Peasant’s Foot (1650) reproduced on the cover of Porter’s book, but all is not well. Weapons of war cover the walls – hooks and a barbed harpoon, crossbow and sword; a less than heartening iconography fills the foreground: a bloodletting bowl by a window, a dead chicken on the floor. On the back cover of the hardback edition is Pieter Breughel’s grotesque Cutting out the Stone of Madness, or an Operation on the Head, in which patients in various sorts of restraint are being tortured by hideous-looking monks and nuns with tongs and picks. The US edition has the unambiguously triumphalist, but no more reassuring, Agnew Clinic by Thomas Eakins: the surgeon-hero.

Surgery and psychiatry probably account for more than their share of harm and unnecessary risk, but Porter is often inclined to spare us the more frightening details. The Portuguese doctor Egas Moniz won a Nobel Prize for purportedly showing that frontal leucotomies – surgically severing the fibres between the frontal lobes of the brain – could help depressed and obsessive patients. Icepick-like instruments, passed through holes drilled in the skull or through the orbit of the eye, gouged out large sections of the brains of tens of thousands of patients, mostly in state hospitals, who were awake during the procedure. The results were dubious but still he won the Prize.

The list of dangerous and unnecessary surgeries is very long; Porter says that ‘the body became like the dark continent’ to the surgeons of the 20th century and they set out to explore it: relatively benign tonsillectomies (a study in the Thirties of 1000 New York schoolchildren showed that 611 had had their tonsils removed and that after a succession of medical panels examined the rest, only 65 were thought not to need the operation); ghastly pneumothorax operations for TB in which enough ribs were cut out to collapse the lung, in the vain hope that ‘rest’ would cure the disease; the removal of large sections of gut to cure constipation and prevent ‘intestinal stasis’ – the signature operation of one of Britain’s greatest surgeons; hundreds of thousands of hysterectomies, performed for all manner of relatively minor ‘female complaints’ before the women’s movement put an end to this particular vogue.

We do not know how future generations will look back on us but a Congressional study in 1974 found that 2.4 million unnecessary operations were performed in the US each year, costing 12,000 lives and four billion dollars. It is not reassuring. Nor are other specialties innocent. They, too, have their overhyped treatments (interferon); their quick fixes (tranquillisers prescribed as a cure for boredom and other social malaises); or thalidomide, thought to be especially free of side-effects. The war against cancer has not been a brilliant success, but its violence on the clinical frontline is awesome, a Passchendaele of the body.

Porter’s is perhaps the first major post-Holocaust undertaking of its kind and we will never be able to view the history of medicine in as sanguine a way as we once did. He retells the story of German and Japanese experimentation in all its sordid detail and makes it clear that far from being something that can be shunted off into some byway, it was, on the contrary, work on the frontier carried out by major medical scientists. Ferdinand Sauerbruch, perhaps the greatest German surgeon of his generation (famous in my family because my Tante Elli had the honour of having her gall bladder removed by him), was an enthusiastic Nazi, happy to have so much new ‘material’ for study. He got his major academic post back after the war and operated well past the days when his hands or mind were up to the task. An eminent German liver researcher was in charge at Bergen Belsen.

Even without the Second World War, the long history of human experimentation which made medical progress possible looks pretty sinister – or, at best, morally ambiguous. Smallpox inoculation was first tried out on prisoners; James Marion Sims practised his operation to repair vaginal fistulae on slaves; William Fletcher showed that 25 per cent of the asylum inmates in Kuala Lumpur who were fed polished rice alone got beriberi but only 2 out of 123 who got the unpolished variety developed this particular deficiency disease; after inmates in asylums and orphanages in the American South got pellagra and the staff did not, further experiments with restricted diets on ‘volunteer’ prisoners established what was missing; birth-control pills using dangerously high doses of hormone were tested on poor women in the Caribbean; and as I write, Cornell University is under scrutiny for an Aids study in Haiti: couples in which one partner is infected with the virus are explicitly not told about the use of condoms and other prophylactic measures, nor given state-of-the-art treatment, in an effort to study means of transmission.

Porter is relatively restrained in telling all of this. True, ‘in 1837 Philippe Ricord (1800-89) established ... through a series of experimental inoculations from syphilitic chancres’ that syphilis was different from gonorrhoea, but one could be more brutally specific. Ricord’s ‘experimental inoculations’ entailed introducing into the bodies of scores of unsuspecting healthy men pathogenic substances which resulted in a fatal disease (syphilis) or a painful and debilitating one (gonorrhoea).

Vivisection will never look quite the same after the Holocaust. The 19th-century novelist Marie Louise de la Ramée, a.k.a. Ouida, had observed that the great vivisectors more or less admitted that they would need human subjects for their research. Of course, the path from a Claude Bernard or a Karl Ludwig to a Mengele or an Ishii (the Japanese doctor who pioneered germ warfare research by testing on human subjects just how much of a lethal bacterium was needed to produce a successful epidemic) is not straight. Anti-vivisection (paradoxically perhaps), vegetarianism and homeopathy all found significant support among the Nazis. And since Porter only alludes to the connection in a footnote, I do not want to make more of the point here. But even if the great physiological research traditions of the 19th and 20th centuries were inconceivable without experiments on live animals there is something dangerous to the spirit about being able to function so coolly in the face of such pain.

The problem was there from the beginning. Harvey’s discovery of the circulation of the blood was predicated not only on old-fashioned Aristotelian thinking and the new mechanistic philosophy but also on being able to cut open the chest of an unanaesthetised dog – taking care to keep the pleura intact – and watching the heart beat as the animal howled and struggled in its restraints. (This beast, like others in medical illustrations, looks weirdly calm in its desperate predicament.) Moreover a good deal of gratuitous pain was inflicted in the name of medicine, and science more generally, with no pretence of furthering knowledge. The unsuccessful prosecution of the French psychiatrist Valentin Magnan in 1874 under an Act designed to prevent cruelty to animals probably did not, as some claim, put a real damper on British research. It certainly did not put a halt to a brilliant experiment. Magnan was merely ‘demonstrating’ the well known fact that giving absinthe to a dog would cause it to have an epileptic seizure. Joseph Wright of Derby’s terrifying painting of a bird being asphyxiated in a bell jar by the members of a provincial scientific society depicts an ‘experiment’ repeated more than a century after the importance of air for respiration had been confirmed with a similar apparatus. Porter does not suggest that there is anything nasty or sadistic about doctors in general and I am perhaps introducing a strain of polemic which he would reject. But this book is redolent with a violence which transposes the narrative of medical triumphalism into a minor key, more tragic perhaps than ironic.

Among Porter’s many virtues is his insistence that medicine be seen in its broad political context. Of course, it has never existed in a vacuum and takes on specific political meanings in each age. The ideologues of the English Commonwealth and, later, the Nazis and, later still, Prince Charles have all held up that curious Renaissance iconoclast Paracelsus as the patron of alternative medicine. The idea that all disease was in essence spiritual represented an alternative to élitist institutions such as the Royal College of Physicians – ‘I am not ashamed to learn from tramps, butchers and Barbers’ – and to the institution of bookish learning in general. But it is during the Enlightenment that medicine and politics became permanent bedfellows. The state began to take a serious interest in health, and doctors by and large leapt at the opportunities this provided.

Porter is in his optimistic mood when he describes the role of medicine in public health, and in broadening our understanding of health and disease. Social medicine is basically a positive development. So, too, are various state-sponsored prevention measures, clean-ups, and epidemiological studies. But there is unease here as well. As public health began to be policed, there was also a real potential for abuse: the poor, for example, were sent to quasi-custodial institutions for TB where they were subjected to austere conditions and occasionally to horrible ill-treatment, while the rich could make their own arrangements. More generally, the view that society would become like a well-behaved patient (the formulation is Lyon Playfair’s), that life could be regulated for the public good thanks to medical knowledge, led directly to the abuses of 20th-century eugenics and other health policies.

Although Porter might resist the suggestion, his history is in some degree influenced by the views of Foucault and Maurice Canguilhem, who argued that ‘life’ as we understand it became an object of study in the early 19th century and that its regulation opened a new arena for the exercise of power. (We do not need 20th-century thinkers to make this point. The Archdeacon of London, opposing civil registration in 1839, argued that when we allow ‘baptism’ to become ‘birth’ and ‘burial’ to become ‘death’ – i.e. when we allow the biological category to replace the religious one – we are inviting the state into our bedrooms.)

It seems therefore that there is a direct trajectory from Liebig’s claim that ‘God has ordered all creation by weight and measure,’ through the articulation of the notion of homeostasis (the capacity of the body to maintain its state) and the invention of instruments to measure and establish this state (norms for blood pressure and temperature were established in the late 19th century) to contemporary medicine’s criteria for normal weight, height, beauty and a wide range of physiological functions. In the end, the human machine can be gauged, regulated and manipulated when it suits the state. This may produce an improvement in public health, but once again, the history of public health is largely unconnected with the history of therapeutic progress. And this ‘normalisation’ places medicine, for better or worse, at the very heart of the exercise of what Foucault called ‘bio-power’, bringing what we might regard as the broad sweep of human life under a single discipline: medicine.

Porter’s ironic counter-narrative to the story of medicine triumphant does not rest primarily on this or that specific danger, or on the cumulative history of violence and abuse, or even on the brooding sense that we are becoming the creatures of a discipline whose reach far outstrips its grasp. What it draws on, I think, is medicine’s claim to be the cutting edge of modernity. Its spectacular technological successes and massive public presence have made it the primary arena (environmental issues would be the only serious competitor) for thinking about the great questions of the day, particularly the question of limits. We seem to believe that medicine can overcome nature and scarcity. And not entirely without reason. Intensive-care units have machines that can breathe for us and feed us almost indefinitely. (Porter doesn’t tell us enough about the rise of this technology in the Sixties.) Reproductive interventions of all sorts allow fertility to transcend old boundaries. Yes, it’s expensive, but few people pay directly.

Many of us have had the experience of taking the old clunker to a mechanic for what we hope will be one more fix-up – just get it through the winter – and being told that the cost of the new hoses, transmission mounting, struts and so on is probably ‘not worth it’. We make a rational economic decision; we wish we had made it on the last visit. In neoclassical economic terms, we calculate whether at the margin it is worth making one more unit, spending one more dollar. But while we might be able to treat the body as a machine to be fixed up, we cannot quite think of it as the old clunker, no longer worth the extra expense. Increasingly, medicine has become, in the words of Sir David Weatherall, a series of ‘expensive symptomatic patch-up procedures’ and we do not have the cultural tools to resolve this dilemma. A recent article in the New York Times on the role of medical devices in raising medical costs told the story of a baby boy born at 22 weeks and weighing 1.25 pounds. Ten years ago this would have been a stillbirth. But the boy was saved; he cost $1.25 million and his happy mother proclaimed: ‘I don’t think you can put a price on a human life. It’s worth every dollar spent.’ It is easy enough to share her joy, but this is a claim that can be made only by someone who is not paying the bill or who is living in a world of limitless resources.

Finally, there is death. At the beginning, with Vesalius, it came under the medical umbrella; the dead body would later become the laboratory of the great 19th-century tradition. Now technology promises to keep death at bay. The ramparts of nature seem to have been carefully studied and finally surmounted. The cutting edge of modernity – endless improvement – has left us with Post-Modernity, with the sense that the old narratives are not as rigid and cogent as we once thought and that all sorts of endings, or non-endings, are possible. In one key instance, the still inevitable end of life, this has so far turned out not to be the case and nowhere has biomedicine proved to be more clueless than in the face of what is still the final dénouement.

Porter ends inconclusively and perhaps that is the best we can do for now. It might turn out that we are living at the end of a technological era which began with the discovery of germs as pathogens in the late 19th century and ended ... we do not yet know when. (Perhaps future historians will date the beginning of that end to the discovery of the structure of DNA.) Like iron-makers in the 18th century we have run out of wood, we can go no further, and we stand at the brink of a new world. Molecular biology will make the high-cost technological patch-up medicine we now live with as quaint as pre-coal smelting, or textile manufacture before the steam engine.

Maybe. But medicine seems also to be like a great religion which, unlike an ascendant Christianity, has failed to make space for local cultures, for other wisdoms, for syncretism. The way out of our present discontent is clearly not so-called alternative medicine. Porter is sure that, as an all-encompassing strategy, it is more dangerous, if less expensive, than so-called regular medicine. ‘The greatest benefit to mankind’ needs a pause for reflection. And the history of medicine, like the history of the West more generally, needs a new narrative. The march of progress will no longer do.