Hitherto there has been no up-to-date and readable single-volume history of medicine. Roy Porter has now made good this deficiency; learning in the process, he says, why so few have attempted this foolhardy task. Porter himself has succeeded pretty well, though it may be that most readers will dip into the book selectively rather than read it from cover to cover.
Porter's aim is to set "the history of medical thinking and medical practice at stage centre". However, he disavows any Whiggish view of medicine as a triumphalist progress towards enlightenment; indeed, his constant theme is that the importance of medicine has lain only to a small extent in its ability to make people better. It is probably only in our own time that it would have been possible to write a history of medicine from this point of view.
The book has a global scope, and includes chapters on Indian and Chinese medicine, but it concentrates mainly on "Western" medicine, which is today the dominant form throughout the world. It begins in antiquity with the Hippocratic tradition, and then moves on to the Middle Ages. Mediaeval medicine, Porter thinks, has had an unfairly bad press; it was not exclusively based on superstition, and indeed when the Renaissance arrived it produced an increased tendency to rely on authority in the writings of Galen. But the study of anatomy was taken to a new level in the Renaissance by Vesalius, and this was an essential basis for later developments.
Another major advance in understanding came about thanks to William Harvey, whose demonstration of the circulation of the blood was a conclusive refutation of Galenic physiology. Paradoxically, however, Harvey by no means favoured the idea of the body as a machine. On the contrary, he was an Aristotelian in his belief in vital forces, and he pictured the heart as forming the centre of the body in the way that the sun forms the centre of the solar system; this was an echo of the macrocosm-microcosm correspondence. In his adherence to premodern ideas of this kind in spite of the revolutionary character of his own discovery, Harvey resembles his contemporary Isaac Newton.
The Enlightenment witnessed the world's first controlled clinical trial, when in 1754 a Scottish ship's surgeon, James Lind, tested the ability of oranges and lemons to prevent scurvy. Twelve patients were chosen and were divided into pairs, who were given different forms of treatment; only those receiving the fruit recovered. But Lind did not think that this result was evidence for a deficiency state in the modern sense; he believed that scurvy was caused by damp air which blocked normal sweat, and that lemon juice acted as a detergent to allow the sweat to run freely through the pores. As so often in medicine, a treatment succeeded although it was based on incorrect theory.
Scientific understanding of physiology and disease processes really took off in the nineteenth century, thanks to researchers such as Louis Pasteur, Robert Koch, and others. Porter brings these men to life, not just as scientists, but also as human beings. An important clinical development in this period was the invention of the stethoscope by RTH Laennec in 1816. He was already familiar with the technique of applying his ear directly to a patient's chest, but confronted with a stout young woman with heart disease he felt that this would be inappropriate, so he thought of rolling up a sheet of paper into a tube and using that. This worked so well that he went on to use a one-ear wooden trumpet; in 1852 an American physician extended the idea to produce the modern instrument. Thanks to his stethoscope Laennec became an expert on examining the chest, but unfortunately he suffered from tuberculosis himself and died at an early age. Another important innovation in the nineteenth century was the introduction of chemical anaesthesia. Porter describes this, though he does not mention the slightly earlier use by Esdaile and others of hypnotism for surgical analgesia.
There has been a general tendency for advances in scientific understanding to predate practical therapeutic applications by a considerable time. Thus, although many discoveries were made in the nineteenth century there were few practical applications. But the twentieth century saw the introduction of genuinely effective treatments for the first time: insulin, antibacterials, cortisone. Surgery improved as well and became more closely linked to the rest of medicine. However, Porter, like many other historians, has no doubt that improvements in social conditions, hygiene, and diet were more important than purely medical advances in improving people's health. He is also scathing about the modern tendency towards medicalization of life. This is apparent in many areas but perhaps particularly in relation to psychology and attitudes to sex.
A sombre theme runs through the later chapters. The Nazis and the Japanese both used human beings as experimental subjects, including for trials of bacteriological warfare. But these totalitarian regimes were not the only offenders; democracies are guilty as well: the American military, for example, carried out secret radiation tests on troops.
And what of the future? Porter doesn't seem to be an optimist. AIDS is a world-wide epidemic, though the worst prognistications have not been fulfilled. Other viral epidemics may well occur and may be even worse. Another threat, which Portern doesn't discuss, is the increasing problem of widespread antibiotic resistance, which may even return us to the state we were in before the discovery of antimicrobials. Meanwhile, as he justly remarks, we are becoming "locked within a fantasy that everyone has something wrong with them, everyone and everything can be cured." For some, alternative medicine is the solution, but Porter doesn't think so; it may, he says, be just as "medicalizing" and risky as the orthodox medicine it seeks to replace. After a quarter-century's experience of the alternative scene, I can only agree.