Review: Blood And Guts: A Short History Of Medicine by Roy Porter. (W.W. Norton, 199 pp.) 2003

- Haim Marantz
Department of Philosophy, Ben Gurion University of the Negev
Beer Sheva, Israel
Eubios Journal of Asian and International Bioethics 13 (2003), 189-91.


In 1997 Roy Porter published The Greatest Benefit to Mankind which was accurately described on its blurb as a "perfectly magnificent intellectual history of medicine [filled with] wisdom and insight [and] a plentitude of information." What Porter attempts in the book under review is to provide an up-to-date and readable single volume history of medicine. The result is Blood and Guts: A Short History of Medicine. Its blurb describes it as "an eminently readable, entertaining romp through the history of our vain and valiant attempts to heal ourselves." This verbiage is meant to attract potential purchasers. What Porter has given his readers is, as always, "eminently readable", and "entertaining", but it is far from a romp except in the sense of its brevity. It is a very serious work and is obviously some type of précis of The Greatest Benefits to Mankind.

This book was based on a course of lectures Porter gave at the Wellcome Trust Centre for the History of Medicine at University College London. Like a good course of lectures Blood and Guts is organized in sequential sections, in such a way that the reader is constantly made aware where he is while pursuing every chapter and how its contents pertains to that of the whole. In effect, Porter has organized the book by following the guideline set in the first sentence of his epigraph, the famous aphoristic line of Hippocrates: "The art [of medicine] has three factors, the disease, the patient and the physician." His opening chapter is about diseases, his third is about the patient's body, and all but one of the others is about the methods used by physicians to diagnose and treat. The one exception is the final chapter, entitled "Medicine in Modern Society".

Porter's first chapter "Disease" is written from the perspective that the illnesses characteristic of any historical period are consequent to the conditions under which people at that time lived. Thus, infectious diseases were probably rare during man's early days on earth, since their spread requires a level of population density that did not exist among the small and scattered groups in which hunter-foresters roamed. As more organized and stable communities developed, they did so in direct proportion to their ability to plant the soil and to domesticate animals. Agricultural societies often came to depend on a single grain such as corn or wheat, leading to a constant level of nutritional diseases that were primarily due to deficiencies of vitamins and minerals. "Pathogens which had once been exclusive to animals became transferred, through long and complex evolutionary processes [within the microbes] to man; animal diseases leapt the species gap and mutated into human ones." (p. 7)

 The list of ailments and microscopic invaders that human beings have acquired from contact with vertebrate animals and the insects associated with them is long. We humans share sixty diseases, for example, with our best friend, the dog. When those diseases are added to those that are the product of the dependency of humans on specific tracts of land and a local water supply; we are presented with a formidable array that includes tuberculosis, smallpox, malaria, influenza, colds, salmonellosis, polio, cholera, typhoid, whooping cough, hepatitis, diphtheria, and a wide variety of parasitic ailments.

As population grew, settlements and then cities became increasingly congested, leading to the rapid spread of diseases from one individual to another, and adding to the ever-growing burden of inadequate food for the ever-growing and largely malnourished population. Huge epidemics such as those caused by bubonic plague and smallpox decimated populations and were spread form one country to another by the beginnings of international trade and exploration. Conquest, too, became an instrument of lethal disease, with syphilis, for example, being spread throughout Europe by the movements of armies and their camp followers after its first appearance on the continent in 1493. The Spanish unleashed wave after wave of measles, influenza and typhus on an American population so susceptible that the resultant carnage became a virtual massacre of indigenous peoples. A few centuries later, typhus would become the most feared disease of conquered nations, as well as of the soldiers of the armies that did the conquering. In the nineteenth century, the international migration of large numbers of indigent people caused a pandemic of cholera, while typhoid killed thousands when water supplies were contaminated.

Industrialization brought prosperity to some, but with it came the occupational ailments of the workers who toiled in the new plants and factories often labouring and living in squalid conditions that spawned infections and deficiency diseases throughout the nineteenth and early twentieth century. But with prosperity came more generalized problems. Diseases of affluence which are the present plagues include those due to simply living so long, doing less manual labor, and indulging ourselves and the manufacturers of the foods and other products that we in the advanced industrialized world over-consume every day. Thus, we have inflicted obesity and coronary heart diseases on ourselves, as well as cancer, hypertension, emphysema, stroke, alcoholism, motor vehicle accidents, addiction, and an array of degenerative diseases such as arthritis, osteoporosis, and Alzheimer's, to name but a few. As has been true of our forebears in every era, we men and women of the twenty first century are victims of the way we live.

Porter devotes a single chapter to the human body and way in which its workings were gradually discovered. But it is a chapter in which he manages not only to hit the highlights, but to make certain observations about what he regards to be the one principle that lies at the heart of both Western medicines enormous success and failures, a principle that so many critics have identified as "seeing". Ours is the only one of the world's many systems of healing that depends on knowing precisely how every part of the body actually functions in health and in disease. This means that the highly specific knowledge of the anatomy, physiology, and biochemistry of the organs, tissues and cells must precede any understanding of the ways in which they go awry and the methods available to treat the abnormalities.

A modern biomedical physician attempts to "see" in his minds eye the very details of every disorder he discovers. The success of his therapies is in direct proportion to the state of the science that has enabled him to see what is actually happening within his patient's organs and cells. But to reach the state of achievement that made this necessary state of affairs possible, Western medicine has had to focus that seeing gaze on tinier and tinier parts of the people who need its help. The ancient Hippocratic doctrine of treating an entire patient has given way to the treatment of misbehaving molecules. The rewards have been magnificent, but the price has been high. Porter sums up the situation in a paragraph, critically placed after his discussion of the origins and rise of dissection:

The journey deep into human flesh initiated by dissection is what has made Western medicine unique. It has sustained the fruitful conviction that in ever-more-minute investigation of the flesh lies the key to health and disease; even if that has also encouraged a tendency to myopic reductionism, to miss the whole by concentrating exclusively upon the parts. [p. 52]

The key word, of course, is "exclusively". Porter has no quarrel in principle with biomedicine, only with the exclusive way it is used in the treatment of individuals and populations. Having spent his career studying and documenting its rise, he was aware (as few others were) of the ways in which biomedicine's aims and purposes have gradually become contorted into shapes that would be unrecognizable to the early-twentieth-century researcher-clinicians whose only goal was to permit men and women to live in health for the full expectancy of years that nature has prescribed for our species. Human cloning, genetic engineering for enhancement, cosmetic surgery, the prolongation of life beyond its natural span - these have now fallen within the province of Western medicine, long before the art of healing has solved its far more urgent problems.

Because Porter is aware of the essentially social nature of disease he is also aware of the several salients on which it should be confronted. Just as there is a necessary place for biomedicine, there is an equally necessary place for the treatment of the entire individual and the circumstances of his or her life; just as there is a place for funding laboratory investigation, there is a place for funding research in population studies and public health; just as there is a place for providing medical care to those who are able to pay for its high financial costs, so there is a place for providing it at the same high level to those who can not; just as there is a place for bringing the best of medical care to the citizens of nations that can afford the necessary expenditures of money and manpower, there is also a place for bringing its benefits to the citizens of nations far less well endowed. And then there is the question that will never go away so long as resources are finite, as they will always be: should wealthy nations continue their high level of funding for the technological research being done in their universities and research institutes when millions of people are dying for want of ordinary public health measures and the basics of individual care? "Modern medicine at best possesses unique capacities to keep individuals alive, healthy and free of pain" Porter writes, but add, "Its contribution to the broader health environment hygiene and better nutrition, would do far more for the health of Third World nations than sophisticated clinical medicine programmes."

These are the matters that Porter saves for his final chapter, after he has described the rise of the profession of medicine and the development of its treatment modalities and hospitals. His narrative of current biomedical evolutions treats the events and the contributors in a rather standard way, in the sense that the significant information is covered in a somewhat perfunctory summary-of-highlights fashion. It is here that Porter has more than elsewhere in the book succumbed to the temptation of speed; the usual Porterian attention to the larger society is, unfortunately, virtually absent from these pages.

It is also in these somewhat rushed chapters that I spotted a few mistakes that one would not expect a historian of his standing to make. The caduceus, the traditional emblem of physicians, consists of a single snake entwining the staff of Asklepios, the Greek god of healing, and not "two snakes intertwined like a double helix," which is, in fact, the staff of Hermes. Hippocratic doctors did not "pledge to do no harm" - that famous injunction appears in no pledge, but rather as an admonition in Book I of the Hippocratic text Epidemics. The habit of draping a stethoscope around the neck became a common practice in the last 40 years and not with a few decades of the instruments introduction in 1819. (I am sure that there were others that I missed. I am neither a historian nor a medical doctor but a teacher of philosophy).

            Not one of the errors alters by one iota the truth and value of the story Porter tells. Neither his authority nor the conclusions to be drawn from his history are at all compromised by the poor fact-checking. One would wish this to be a perfect book - as it is the last he wrote before he passed away in March 2002 - but it is not. Nevertheless Blood and Guts is exactly what its author intended it to be: an incisive, one volume, and yet expansive history of medicine, and a catalyst for its readers to reflect critically upon the medical profession's faults and to agonize over its current problems.

It is in the sections sketching the development of biomedicine that Porter seems in a hurry to get to the bringing-up-to-date contents of his concluding pages, where he surveys the problems faced by Western Medicine at the beginning of the twenty-first century, a time when its great success has led it increasingly into an era of unattainable expectations and unimaginable cost. Porter sets the tone of his final chapter "Medicine in Modern Society", in the following few sentences:

"Modern health care has turned into a colossal service industry, in both state and private sectors; in many nations it claims a greater share of the gross national product than any other item - these days a staggering 15 percent in the U.S.A. Critics call it a juggernaut, an institution out of control, or at least one driven less by patient need than by profit and professional power. The personal touch so essential to healing, has been lost! This transition from small man to corporate enterprise is the result, in part, of those giant strides in basic and clinical research, and the pharmacological and surgical revolutions discussed in the preceding chapters... The medical machine has acquired an extraordinary momentum." [p. 171-172]

            Porter offers no solutions, and perhaps there are none. But readers of his book can hardly be blamed if a mood of pessimism follows after reading his description of the various ways in which individual nations have attempted to cope with the problems of access, the quality, and the cost of medical care. As he so poignantly points out, tinkering with the increasing problems of the American and European health schemes has not resulted in changes that amount to true structural reform, but "merely a ragbag of cost-capping initiatives, accounting and managerial strategies and short term economies."

And all this is happening at a time when more affluent consumers - that is what patients are nowadays called by American insurance actuaries and the advocates of egalitarian healing practices - are demanding additional services in the form of "the fulfillment and further extensions of life." The spiral demands and expectations grow ever higher matched in magnitude only by the spiral of dissatisfaction among patients and doctors alike.

In the concluding chapter of the book Porter gives voice to an apprehension that, overtly recognized or not, nowadays increasingly influences many of the policy decisions - by governments, or by small research or clinical teams, or even by individual physicians in their consulting rooms - that underlie the growth and provision of medical care. This apprehension can be simple expressed in the question: "Is this something a doctor should be doing?"

So what are the goals of medicine? The seep of its history since the Hippocratic era has seen its goals evolve from the elementary principle of curing disease in individual patients to the gradual realization - reaching its full-blown form in the nineteenth century - that the relief of human suffering, whether of one person at a time or in the aggregate, is an equally worthy objective. Modern medicine began when the physicians retreated from time to time to the laboratory in order to search for solutions to problems they encountered at the bedside; it grew through the cultivation of knowledge that was not immediately useful, until eventually it became an entity and built itself into an establishment.

We have now reached a time when biomedical discovery determines the range

of clinical problems that fall within the realm of a doctor to treat, instead of vice versa. A disease is now a condition for which science provides a treatment; the tail now wags the dog. As a consequence of this development, the definitions of sickness and of suffering have expanded to include all those conditions for which there exist therapies. And so, under the influence of the profusion of miracles bursting forth from the research establishment, people began some time in the late twentieth century to define sickness and suffering in terms of what the laboratory makes possible, rather than in terms of what is necessary for their physical and mental health.

Then again the expanding medical establishment, faced with a healthier population, seems to be driven to medicalizing normal events and treating trivial complaints with fancy procedures. Hence while some claim to have trouble to distinguish between what is treatable and what it is necessary to treat, it is in most instances possible to draw the distinction. While it is possible to shorten the nose of someone who is displeased by its length, it is necessary to repair a cleft palate; while it is possible to grown hair on a bald head, it is necessary to treat heart failure; while it is possible to fertilize an ovum in vitro, it is necessary to provide postpartum care to newborn infants of the poor. I can foresee a time when it will be possible to genetically increase both the height and intelligence of our progeny, but even then it will be necessary to treat malaria and schistosomiasis, that today kill more than one million men and women every year.

The panorama of historical evolution has led us to the point as Porter puts it where "medicine may be on the brink of one of the greatest transformations in its long and chequered history." Enhancement and wish-fulfillment are increasingly possible but they are decidedly not necessary. The history of medicine tells us something of far greater importance: namely, that medicine's long path has not been a smooth trajectory. The apparent arc of its progress has been knocked off course more than once, and sometimes, as is clear from Porter's book, for the better. There is no inevitability to the folly-fraught direction in which we now seem to be heading. But doctors need to be made aware that there is no need to do a thing just because they can do it.


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