The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present.

By Roy Porter (London: HarperCollins, 1997. xvi plus 831pp. [pounds]24,99; also New York: Norton, 1998. $35.00.).

By Constance E. Putnam Tufts University

Roy Porter's latest tome is, in several senses, a weighty matter, not quickly disposed of either in the reading or in the reviewing. Yet the effort is worthwhile - which will surprise no one familiar with Porter's work. The book's genesis, Porter tells us, was his not knowing what to suggest to students and others who asked him "to recommend an up-to-date and readable single-volume history of medicine." In the end, he would have us believe, it was "clear why so few have attempted this foolhardy task" (xvi); writing it, he says, "brought home the collective and largely irremediable ignorance of historians about the medical history of mankind" (13).

If some of the ignorance truly is irremediable, Porter has nonetheless done much in this extraordinary book to push back the darkness. Though unreflective medical historians and well-read laypersons may come away from the book thinking they have not learned a great deal (they will discover as they read that they are already familiar with many - even most - of the persons and issues Porter discusses), no one who reads the entire book carefully will fail to accumulate additional information and knowledge. It is in any case not the encyclopedic quality of the book (necessarily still incomplete and sketchy, despite Porter's march through history and across cultures) that gives it prime value. Rather, it is the synthesis he brings to his enormous subject and the accessibility he gives to topics that in others' hands frequently seem either ponderous or imponderable. Porter's history is neither. A repository of enormous quantities of knowledge, Porter is also unusually skilled at presenting material engagingly and making it easily comprehensible.

Though his subtitle promises a beginning with "Antiquity," his opening chapter actually starts earlier: "The Roots of Medicine" (14-43) sets the context splendidly for the book's largely chronological journey. Chapters on "Indian Medicine" (135-46) and "Chinese Medicine" (147-62) fill in gaps too often left gaping; more familiar topics, like those taken up in the chapter "Pasteur to Penicillin," are deftly handled; chapters on particular areas of medicine - "Psychiatry," "Clinical Science," "Surgery" - pave the way for two chapters at the end that fulfil the promise of the introduction by giving insights into the politics of medicine and the way medicine actually affects people. The closing chapter, "The Past, the Present and the Future," briskly summarizes how it is that the "medical history of humanity" continues to move along a path that is strewn with obstacles and less predictable in its direction than we like to believe.

If at first blush the book's sheer bulk seems its chief feature, Porter hints along the way at the reason. A "patchwork of ideas and institutions, theory and practice, craft and science, involving divided and vying professional factions," medicine "has a generally muddled history . . ."(428). As the book progresses, we hear Porter's views on the current scene: "Modern medicine has been able to root, spread and propagate itself . . . in part because it changed its objectives" (630). We see two sides: "For its fans, modern medicine, with its microbe-hunters and micro-chips, has enabled westerners to escape from the valley of the shadow of death, living longer and healthier lives; for critics this is the era of the Holocaust and the Gulags, in whose unspeakable outrages doctors and psychiatrists were hardly reluctant participants. Scientific medicine may be the knight in shining armour or a new body-snatcher" (669).

As noted above, however, neither number of pages nor control of complex subject matter is the primary asset the owner/reader of this book acquires. Porter's signature is his incomparable ability to balance the general with the specific. Given the centuries and the geography he set out to cover, he could have been excused for skipping specifics. Instead, he seasons the generalities with a generous dose of details - names, dates, diseases, events. The result is a series of mini essays on particular subjects that serve up a fund of knowledge with a degree of coherence difficult to find elsewhere.

A case in point is the fine section (211-16) on William Harvey. Most histories of western medicine mention him and make a passing reference to his work on the circulation of blood. Porter, not content with mere dates and a statement about the importance of Harvey's De motu cordis, explains both the precursors to Harvey's discovery and its significance. This is but one of the many sections in the book that show Porter off as the eminently readable essayist that he is. Examples of his lucid style abound. Deserving particular mention are the explanation of internal medicine (483-87) and the analyses of neurology and neuropathology (534-60), which succeed in making technical subjects interesting and understandable for the nonphysician.

The more general essays that Porter does so well also help turn potentially messy scenes into sharp pictures. One could hardly ask for a clearer snapshot of how medicine fit into the Renaissance (168-76), for instance, and the opening salvo of the chapter on medical research - "Launching a Research Tradition" (525-27) - skillfully prepares the way for that critical transition in the history of medicine. Nor does Porter fail to remind his readers not to succumb to the temptations that latter-day wisdom pose. After giving examples of Roman physician Galen's mistakes (easy enough to do), Porter pricks the balloons of those tethered to ideas of modern superiority: Galen's "explanations of anatomical phenomena in terms of the teleology of a divinely ordered universe were," he points out, "internally coherent and provided a rational basis for further investigation" (75). Any reading of history that does not include this kind of understanding is of course incomplete.

Among the attractive features of Porter's style is the total absence of pretension. One way this shows up is the lack of footnotes; readers can proceed smoothly without being quoted chapter and verse (of course this will frustrate those who want to know exactly where a quotation or other piece of information comes from). But the book is by no means lacking in scholarly apparatus. For one thing, the index is very good (not flawless). Equally important and useful in a very different way is the bibliography of "Further Reading." With nearly 800 titles, this constitutes a veritable do-it-yourself course in the history of medicine for anyone who accepts the challenge; notably, an asterisk identifies the books on which Porter relied most heavily.

In omitting to use footnotes, however, Porter does not take for granted that his readers will be familiar with the tidbits that must seem obvious to him. A small example is the way he casually sprinkles the text with etymological gems: the relatedness of "healing" and "holiness" (84) in the chapter on faith and medicine, the fact that the force responsible for iii health in Islam ("jinn," plural "jinni") is the source of our word "genie" (93), the origin of the word (indeed, the entire concept) of "quarantine" (126) in the 14th century, the literal meaning of "autopsy" (177 - and elsewhere; he repeats himself occasionally), what "diabetes" means, and so on. When he took the trouble to explain that "adrenaline" in Great Britain is called "epinephrine" in the United States, he missed the opportunity to point out that the difference is also one of Latin versus Greek derivation. But the information of this sort he does provide enhances the book for those who delight in such matters but haven't figured out a particular etymology.

Also an enhancement to the learning process as well as the reading pleasure is the fluidity of Porter's style. That he rates as one of the best essayists writing on academic subjects today is a judgment others have made; readers will find their own evidence both in the overall effect and in particular elements of his style. There is boldness: "In the beginning was the Golden Age" (14) and novel imagery: "Diet ... was discussed down to the last lettuce leaf" (267); there are touches of humor: for Astley Cooper and John Hunter, "a day without dissecting was a day lost" (361), and - a propos problems in career advancement - "the characteristic disease of blocked promotion" (385-86). Porter pounds out pithy points with concise statements that force the thoughtful reader to stop and - yes - think: "The madhouse was an ambiguous institution" (494). On radiotherapy: "Therapeutic enthusiasm outran caution ..." (608). On World War II: "Wartime medicine gave doctors a vision and a voice" (642). He can also pull the reader along by the force of his rhetoric, as he does increasingly near the end of the book: "modern medicine is extremely heterogeneous and subdivided, with numerous islands of knowledge linked by an erratic network of often temporary bridges" (554); "the hallowed liberal-individualist Hippocratic model of a sacred private contract between patient and doctor seemed as passe as Smithian political economy in the age of Keynes" (634).

When Porter attacks, he pulls no punches. The topic might be political: "The Poor Law [in England, in 1601] could be seen as the nationalization of religious charity in the post-Reformation Protestant state; it was also a form of social regulation and a prophylactic against disorder" (239); "The [1914 Harrison] Act [in the United States, criminalizing drugs] made bad worse" (665); "Commonsense suggests that the money spent on these forms of cardiology and oncology would be more wisely spent on anti-smoking campaigns, and in research into other diseases" (714). The barbs can also be personal: the conflicts between Robert Gallo and Luc Montagnier over AIDS research he describes as "[u]nseemly wrangles" (594), which degenerated into a"feud" (707); heart surgeon Christiaan Barnard's "published autobiography portrays the author as a man obsessed by success; he became besotted by his opportunities for fame and sexual conquest" (622).

In what is arguably the most stimulating feature of the book, Porter challenges other historians and commentators; the variety and range of these implicit criticisms provide ample evidence of the control this historian has over his material. "Though some modern Jewish apologists argue . . . the fact is . . ." (85). "It is often held that a distinctive Arab-Islamic medicine dates from the time of the Prophet... there is no evidence . . ." (94). "Conventional histories of medicine still retail the view that the Church arrested medical progress.., in general such judgments miss the mark" (110-11). On witch-crazes of the medieval period: "the figure of nine million burnings, often cited in feminist writings, is pure fantasy" (128). On Leonardo and anatomy drawings: "it is wrong to think that the apparent crudity of medieval images reveals ineptitude. Late medieval illustrations were not meant to depict minute documentary detail; they were diagrammatic teaching aids, schematically representing general truths - mnemonic rather than photographic" (133). "The idea that Ayurvedic physicians deal purely in herbs, roots, and therapeutic massage is a nostalgic myth" (146). "[T]he common portrayal of [Paracelsus] as the founder of scientific medicine is misleading . . ." (202). "Harvey did not, as sometimes supposed, conceive of the body in a 'modern' mechanical fashion . . ." (215). "Historians have sometimes explained this apparent paradox of Enlightenment medical science - great expectations, disappointing results - as the consequence of overambitious theorizing. Yet that judgment seems misguided . . ." (248). "Historians have tended to divide disease theorists into rival camps: miasmatists versus contagionists. But that is too crude; much theoretical finessing went on . . ." (259). "[T]he localized disease concepts promoted in Paris were not spontaneously generated, nor . . . did the procedures pioneered in its showcase hospitals transform medicine at a stroke" (307). "'Tropical diseases'. . . do not constitute a single natural class of pathogens; they amount to [a] medley of maladies . . ." (462). On a 1969 claim that the book of infectious disease was closed: "The manifest shortsightedness of that view is a measure of the medical optimism prevalent a generation ago" (491-92). "The real usefulness of coronary care units in keeping people alive has never been put to the test. With its sometimes grotesque procedures, the new heroic medicine may turn out to be yet another instance of reflex preference of modern medicine for the highest-tech fix for a problem" (585). "Until the last hundred and fifty years, the role of clinical medicine in the improvement of health was tiny" (714).

Though Porter remains nicely neutral throughout much of the book, this directness is refreshing and helpful. What emerges are not just facts, but plenty of genuine Porterian analysis. Thus by the end of the book, no reader should be surprised to discover that Porter's tone has become one of sober caution lest we think that, hundreds of pages after primitive medicine, we are necessarily better off. The progress of the 19th-century sanitary movement, for instance, was offset to some extent by the way "patient-power posed threats to professional dignity and autonomy" (636). Surgical successes of the 20th century turned the operating theater into "the high altar of the hospital, and the white-coated, masked and capped surgeon, so cool in an emergency, became the high priest of medicine in images which pervaded popular culture, TV soap operas and the press" (611), just as "[e]arlier optimism about magic bullets and a pill for every iii now seems symptomatic of a shallow high-tech, quick-fix vision of the world, born of the laboratory and expecting the world to be as controllable as a laboratory" (711).

The book is not without a few minor disappointments. For some it may simply be too long, useful more as a reference tool (thank goodness for the index) than as the story of humanity's medical history. Although the details in the book are for the most part wonderfully told, there are times when the welter of names and dates leaves one rather breathless (e.g., 245ff., 277, 318, 452). And though Benjamin Rush always makes good copy in the history of medicine in the United States, one could wish Porter had added less to the ink that has been spilled on him and had instead told more about his fellow Philadelphians William Shippen and John Morgan. Among other things, they and (in the next medical generation) Nathan Smith and Mason Fitch Cogswell - to mention two important New England figures neglected here - surely killed fewer of their patients than Rush did of his. Then, too, Porter recounts the story of the conflict between Jonas Salk and Albert Sabin over how best to fight polio, but he leaves it dangling and incomplete (695-96). And the omission of C. Everett Koop, certainly one of the most prominent and influential figures in late-20th-century medicine, seems odd, especially given the space Porter devotes to struggles over AIDS policies and to anti-smoking campaigns (two of the areas where Koop has played especially important roles).

But choices about what to include had to be made, and these are quibbles - American ones at that; they do not in the end seriously detract from the value of the book. Nor should we be much troubled by a handful of typographical inconsistencies and copyediting errors - italics or no for foreign words, pronouns with confusing antecedents, dash for comma and vice versa, use of full first name and then initials only for the same person, occasional misspelling of proper names - Kinnier Wilson (548) vs. Kinnear Wilson (798); Friedrich Theodor von Frerichs (548) vs. Friedrick Theodor Frerichs (567); confusing or missing dates - 1920 and 1921 cannot both be right (572), and Lewis Thomas (715) died in 1993, for example.

More irritating are the two dozen or so times where a person or event is mentioned prior to being explained. This cart-before-the-horse syndrome, though harmless, can make readers stumble, as when "Huntington's chorea" is mentioned twice (549, 589) before any reference is made to Huntington himself - and then (uncharacteristically) without his dates (629). Also a bit tedious are the repetitions. We are told two times, for instance, that Walter Cannon (dates also repeated) coined the term "homeostasis" (340, 562). This doubling of information may not be a slip, however - better to have the information twice than not at all - but an indication that Porter expects the book to be used for reference more than as a book to be read straight through. And genuine errors are virtually nonexistent. The (common) misuse of "decimate" (166) is one; it may be the only diction error in the book. A second blunder, very odd for Americans, is that even if English figures with unhyphenated double names are correctly listed under the paired name (Southwood Smith, Boyd Orr, perhaps Kinnear Wilson and Hughlings Jackson - sources disagree on these), Oliver Wendell Holmes's surname is not "Wendell Holmes." But add these two errors to the small annoyances and irritations mentioned above, and the sum is still small. And in 800+ pages. . . . After all, even great Homer nodded.

In the end, Porter's take on the route we are following is challenging: "Thanks to diagnostic creep or leap, ever more disorders are revealed. Extensive and expensive treatments are then urged, and the physician who chooses not to treat may expose himself to malpractice accusations. Anxieties and interventions spiral upwards like a space-shot off course" (718). All the more reason, he would no doubt argue, for us to understand how we got to where we are. An excellent place to begin is by reading this stunning piece of work. That is admittedly not a trivial undertaking; the book is unwieldy, as any book of 800 pages would be. It can of course be nibbled at piecemeal (as indicated earlier, there are internal hints that Porter may have expected people to use the book more as a reference tool than as bedtime reading for entertainment or edification). But those who sample selectively will lose the grand sweep of what its author has accomplished. For this book is precisely what its subtitle claims: a "history of humanity." That it is a medical history should not deter anyone; Porter has made the case that, for all its faults and flounderings, medicine has at least aimed to be "the greatest benefit to mankind." Read the book, and you will understand both why and how.

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