r
Medical Hypotheses
7
L
Mdc‘li Hypohws Q Longmtn Gmp
I
(1992) 38.97-101 UK Ltd 1992
Physicians,
Historians, and the History of Medicine
P. PRIORESCHI Creighton University 68 178, USA
School of Medicine,
Department
of Pharmacology,
California
at 24th Street, Omaha, NE
Abstract-For American medical historiography, to borrow from Dickens, these are the best of times and the worst of times. These are the times when rigorous scholarship has been brought to bear on the field (with great improvement in the quality of research) and when medicine is disappearing from its own history. These are the times when, in general, historians know only their field of specialization and physicians know only how to treat diseases. These are the times of focused competence and general ignorance. The history of medicine has become a field where historians write for other historians who, limited by their ignorance of medicine, cultivate mainly its sociological and political aspects. Physicians, on the other hand, are taught that only what is ‘relevant’ counts, and practise medicine in ignorance of their past because the history of medicine does not seem to have any immediate utility (1). The few among them who attempt to do something in what is, after all, the history of therr profession, are often considered, by historians, naive dabblers who tack knowledge and capacity for the task. This state of affairs came to be fairly recently. it began with a positive development in medical historiography: the realization that the history of medicine was not a discipline that helped to treat diseases but the history of one of man’s endeavours, in other words, that it was not a branch of medicine but of history.
The history of medicine as a branch of history
tinued to be regarded as of interest almost exclusively to the physician, who in turn considered it part of his medical knowledge. In other words, he considered the knowledge of Hippocrates and Galen useful to treat pneumonia and dislocated shoulders. Whereas what we today call basic sciences (anatomy, physiology, pharmacology) became sciences earlier, it was only in the second half of the 19th century that scientific clinical medicine began evolving to become eventually what it is today. This entailed a reassessment of the meaning and function of the his-
Until the beginning of the 19th century, Hippocratic medicine was still taught at the School of Medicine of the University of Paris and the medicine of the remote past was studied not as history, but as knowledge useful for the treatment of diseases. It is true that from the end of the 17th century to the end of the 18th, some histories of medicine were written (e.g. those of Le Clerc, of Friend and of Sprengel) that showed a trend toward a more historical interpretation, but, by and large, the history of medicine conDate received 17 June 19Y 1 Date accepted 30 September 1991
97
98 tory of medicine. But the process was slow. In 1889, Baas could still write: The history of medicine, of all the branches of that art, is the one to which least attention is devoted by physicians; and yet its study not only possesses great scientific value, but likewise includes an important germ of practical information (2)
He thought not only that the history of medicine was a branch of medicine but also that it was of interest to physicians because it still ‘included an important germ of practical information’. The times, however, were changing. Historiography in general had come of age, and scientific clinical medicine proceeded to build on the solid bases set by the scientific revolution in the previous centuries. The historiogmphy of medicine also had to undergo change. In the first half of the 20th century the first centers for the study of the history of medicine were founded in Europe (in 1905, at the University of Leipzig) and America (in 1929, at the Johns Hopkins University) but the discipline was still practised mostly by amateurs (usually physicians) although serious studies were becoming increasingly frequent. Slowly, its practice started to drift from physicians to professional historians. This trend was seen with some apprehension by the former although the importance of the contributions of historians and other non-medical professionals was well understood. Sigerist, a physician, in the introduction of his A History of Medicine wrote: It would be a mistake to assume that medical history today is a concern of historians and philologists alone and of no interest to physicians. Medical history is medicine also, today as it was in the past. We shall have to demonstrate this. Several generations of philologists and historians have made valuable contributions to the field. They did most of the spade work, made sources available, and, by looking at medicine from the outside, brought in interesting points of view. It seems to me, however, that today more than ever there is need also for medical interpretations and evaluations of the past of medicine (3).
This was in 1951. We are now close to the end of the 20th century and we have to conclude that the healthy process of evolution of medical historiography, as it passed from the hands of physician amateurs to those of historians and other non-medical professionals, has gone too far. There is no doubt that it was indeed necessary and beneficial that strict scholarly criteria be applied to medical historiography. Modern methods of social
MEDICAL HYPOTHESES
and historical analysis were brought to bear in this field as they were in other branches of historiography. The history of medicine ceased being exclusively a chronicle of discoveries and biographies of great physicians and became a study of the healing arts in the context of social, political, and cultuml changes. However this did not mean that physicians were no longer needed in medical historiography. Yet, the result was that they withdrew from the field. The history of medicine came to be perceived by the profession as an esoteric field, dangerous to tread, to be left to the specialist. In addition, the curriculum of the medical scientist became more and more technical and a humanistic education came to be seen as useless for the pursuit of a medical career. The physicians no longer learned Greek and Latin, no longer were familiar with philosophy and history, no longer were interested to know, in the words of Sigerist ‘what the Greeks, the Romans, the people of the Renaissance had done to protect and restore their health and what ideas had been guiding their actions’ (3). Ignorance of the history of their own discipline was the result. Nuland recently wrote: Today’sprofessors (of medicine) are no better equipped to speak of William Harvey, for example, than they are to quote Marcus Aurelius. The operating or rounding clinician who makes reference to a historical event is at best considered to be a raconteur of reconditeness; at worse (and I fear this is more often the case), he is seen as a harmless fogy whose recollections get in the way of the serious work at hand (4).
As physicians withdrew, medical historiography became more and more concerned with the non-medical aspects (especially the sociological and political ones) of the history of medicine and physicians who intruded in the field were increasingly resented. Again in the words of Nuland: Another of the major criticisms directed at the presentday profession of medical history is that it is largely a fraternity of scholars untrained and uninterested in clinical medicine, and sometimes antagonistic to its practitioners. Many of the issues with which it concerns itself are seen... as ‘medical history without medicine.’ This is a criticism that I think is valid, or at least valid enough that it must be addressed. Just as there are insights and interpretations that only a social and a cultural historian can bring to the study of medicine’s past, there are insights and interpretations, at least as signtficnt, that can only be supplied by men and women who are involved in the art and science of healing (4).
This is what the situation is today. Unfortunately, however, this hiatus between historians and physici-
PHYSICIANS. HISTORIANS AND THE HISTORY OF MEDICINJZ
an:; has had other unhappy consequences for medical historiography. Scientific ‘truth’ and scientific progress The withdrawal of the physicians, that is of the scien-
tists, from medical historiography has caused misconceptions about certain fundamental tenets of science and medicine among medical historians. Here are a few examples. In a book review we read: This chronological account is accurate, straightforward, and well written, but suffers from an overriding contemporary scientific bias... the book chronicles
the progressive accumulation of ‘correct’ knowledge a.bout digitalis, as the pathophysiologic perspective of 1’9th and 20th century physicians replaces the rather ‘primitive’ perspective of their forebears (S).
Obviously the reviewer is laboring under a non-scientific understanding of what scientific progress and truth are (see below). This makes him unaware of what should be evident: in view of the fact that today we know more about digitalis (in other words we have more accurate information concerning the actions of the drug) and therefore we can better use it to treat disease, why should we refrain from comparing our knowledge from that of our forefathers? Don’t we expect that those who will follow us will also compare our ‘primitive’ knowledge with their more advanced one? Is this not one of the raisons d’etre of the history of science? Another example: Topoint
out the fact that health care beliefs make sense
in the context of culture represented a significant step forward from earlier notions that discriminated only between truth, science, and rapidly advancing modern medicine, on the one hand, and false, irrational, and static beliefs, stubbornly adhered to by uneducated pr,imitives, on the other hand (6).
There is no question that health care beliefs make sense in the context of culture; there is no question that if this was not realized by previous historians it should have been; there is no question that the awareness of the importance of the cultural context represents, a significant step forward, but it should be obvious t.hat there is also no question that we must make a distinction between truth and science, on the one hand, and false beliefs on the other (the ‘irrational... static. .. stubbornly adhered to by uneducated primitives’ was added by the author simply for the sake of color, of course). Aulus Gellius (7) states that the
99 reason, given by Apion, for which the ancient Greeks and Romans wore a ring on the next-to-the-left little finger was that the Egyptians had found a very fine nerve going from that finger to the heart. Should we refrain from saying that this quaint notion, interesting as it may be, is anatomical nonsense? And another example: (One possibility would be) to label the Near Eastern scientific achievements as a ‘pre-scientific’ stage... However, such practices are so obviously ethnocentric and naively self-gratificatory that they cannot be accepted. They belittle the intellectual achievements of mature civilizations by a priori characterizing them as a preliminary phase, a preparatio Evangelli, which is to usher in one’s own civilization (8).
One would think as self-evident the fact that the use of the term ‘prescientific’ does not belittle anybody or any civilization. The expression simply recognizes that there are stages in human history and that as there was a ‘pre-industrial’ era so there was a ‘pre-scientitic’ one. Obviously there is nothing ‘ethnocentric and self-gratificatory’ in observing that our and other civilizations, at a certain time, were in the pre-industrial or pre-scientific stage (again, the ‘preparatio Evangelii’ is there for color). The last two quotations, like the first one, suggest that their authors have concepts concerning science, scientific progress and scientific truth that differ from those usually held by scientists. The origin of such concepts, which are so common in contemporary medical historiography, have their roots in problems of modem epistemology which have degenerated into a contemporary all-embracing relativism. In modem times, several philosophers (Locke, Berkeley, Hume, Fichte, Kant, Bradley) investigating the so-called ‘problem of knowledge’ have shown that a simple correspondence between sense data and reality could not easily be assumed. More recently, Heisenberg, a physicist, with his famous uncertainty principle, has shown that, at least at the subatomic level, physical reality may not be simultaneously knowable in all its aspects. This, of course, cast a shadow on the validity of our knowledge of the external world and, in turn, raised the question of the ‘relativity’ of scientific knowledge, that is to say, whether the natural laws that are the object of scientific knowledge do exist in themselves or if they are the creation of the human mind. In spite of all philosophical doubts, however, it is evident that the scientist must assume that there is a concrete knowable reality otherwise science and scientific research would not exist: only if Parkinson’s disease has a knowable pathogenetic mechanism, can
100 we hope to find it; only if black holes are regulated by laws that are knowable does it make sense to seek them. As a consequence, scientists conduct their research as if there were a perfect correspondence between sense-data and reality and assume that there is a natural ‘truth’ that they are striving to discover. What we call ‘science’, in fact, is the ongoing progressive process of discovering such ‘truth’. The process brings us closer and closer to the goal even if, it is assumed, never quite up to it (as if it followed an asymptotic curve). For this reason any accepted scientific explanation is considered a temporary hypothesis ready to be replaced by another that is closer to the ‘truth’. This, of course, constitutes what we call scientific progress. This being the case, two consequences, which are of importance in any discussion of the history of medicine and of science in general, result. The first one is that contradictory explanations of natural phenomena cannot be equally valid and, therefore, one has to be better than (that is, superior to) the other (e.g. the Ptolemaic and Copemican paradigms cannot both be equally good explanations of the solar system; the pathogeneses of pneumonia according to modem medicine and to traditional Chinese medicine cannot both be correct). One is superior to the other for theoretical reasons (one is ‘truer’ than the other) and often for practical reasons as well (the Copemican system better explains the observed phenomena; modem ideas of the pathogenesis of pneumonia allow us to better understand the morbid process and, consequently, to devise a more effective treatment). The condemnation and indignation expressed in the quotations above about lamentable ‘contemporary scientific bias’ and about the wrongness of thinking that many scientific beliefs of primitive people were false are therefore unwarranted. The second point is that, in the pursuit of scientific knowledge we must use the tool that is most apt to further such knowledge. Experience has shown that, so far, the scientific method (which is defined as the collection of data through observation, the formulation of hypotheses, and the confirmation of the hypotheses by experimentation) is such a tool. It is evident, however, that there is nothing inherently sacred about the scientific method. Obviously, if somebody were to find out that after meditating (or drinking a certain potion) one would acquire new insight into the laws of nature, i.e. if the meditation (or the potion) would reveal to us a better cancer therapy or give us a new insight into the structure of Halley’s comet, then the scientific method would
MEDICAL HYPOTHESES
have to be discarded in favor of meditation (or potion drinking). So far, however, this has not happened. The scientific method seems to be, by far, the best tool for acquiring new scientific knowledge although the latter may also be obtained by other means (e.g. trial and error, intuition). For this reason it is entirely correct to assert that, as far as science is concerned, any society in the ‘scientific stage’ is more advanced than one in which the scientific method was (or is) not applied, that is, than any society in the ‘pre-scientific stage’. In view of the above, should we consider scientific medicine the standard against which all other medicines are measured? Of course we should. In the same way as scientific physics is the bench mark against which all beliefs concerning physical phenomena are to be measured. This is because scientific knowledge is the closest to the natural ‘truth’ discussed before. It is evident then that, for this reason, some ancient scientific ideas were wrong (‘false’ or less ‘true’ than ours) and that it would be absurd not to say so. It would appear that the beliefs quoted above concerning scientific truth and scientific progress, and other similar beliefs so common in contemporary medical historiography, are due to their holder’s lack of experience in science and, in some cases, to their training in history and/or philosophy. Such training would naturally predispose them to emphasize philosophical doubts and to neglect the scientific point of view. In addition, those doubts would tend to reinforce the inane relativism, so common in contemporary thought, according to which all opinions, all beliefs, all behaviors, all vices, all virtues, have equal validity. We have seen that science, from this point of view, is the antithesis of relativism because, contrary to it, it establishes hierarchies of validity, it strives to find what is better and what is worse , what is superior and what is inferior, what is valid and what is not. As noted above, not all scientific views, ideas, and opinions can be equally valid: when two oppose each other, one is usually closer to the ‘truth’ and therefore superior to the other, that is, better than it. Historians and historian physicians
It is not hard to detect a degree of resentment on the part of professional historians (even of those who are not ‘new-wave’) toward those physicians who dare to enter the field of the history of medicine without formal training. A common utterance heard in defence of such attitude is ‘How would you feel if a historian were to practice medicine without training?‘. The
PHYSICIANS,
HISTORIANS
101
AND THE HISTORY OF MEDICINE
point is, of course, invalid. It is invalid because of an asymmetry that exists between science and the humanities, the same asymmetry that allows a physicist to be a poet but forbids a poet to be a physicist. It is evident that a poet cannot, without training in the field, be a physicist because physics has such a high degree of esoterism that only a specialist can master it. The degree of esoterism can be operationally defined as the inverse of the extent to which a certain discipline or field may be familiar and explored by the educated non-specialist. For example, we all can (and often do) read (and sometimes even writ.e!) poetry, history, or literature and some of us, without formal training in the field, may be familiar with the poetry of Petrarch and the history of the French Revolution and be quite knowledgeable about the works of Tolstoy. On the other hand, how many of us non-specialists read (let alone write) works on nucl.ear physics or are familiar with the UhlembeckGotidsmit theory and are knowledgeable about the Pauli exclusion principle or the SchrMinger wave equation? It is conceivable that a physician, untrained as a poet, could write poetry because, although the writing of poetry requires many qualities and capabilities, it has a low degree of esoterism. This, of course, does not mean that physics is more difficult than poetry. Not at all. In fact, good poets are rarer than good physicists. It simply means that whereas a physicist without any particular training in poetry could write a good poem, or even be a good poet, a poet without training in physics could not be a physicist, let alone a good physicist. Olbviously this applies not only to poetry and physics, but to all human intellectual endeavors. The degree of esoterism of each endeavor or discipline cannot be objectively measured, it can only be assessed through operational evidence: the fact that someone without specific training could write a novel but not be a physicist indicates that literature has a low degree of esoterism and physics a high one. What about other disciplines? All have different degrees of esoterism that can be roughly assessed only by comparison. If we consider poetry and physics as the two ends of the spectrum, it would appear that, for example, literature, history, sociology, medicine, and chemistry would fall in between, more or less in that order. It stands to reason: if we were to hear that a certain expert on Dante or on the Thirty Years War had no formal training in literature or in history, we would not be terribly astonished, but it would be astonishing inded if a professor of Latin literature, with no training in medicine, was an expert neurosurgeon.
It is, of course, because of this asymmetry between science and the humanities that a physician without formal training in historiography could be a historian (especially a medical historian) but not vice-versa. Once this point is clarified, we must address the question: how important is it that physicians contribute to medical historiography? It is essential. In the same way that it is essential for the historiography of mathematics that mathematicians contribute to it, and for the historiography of astronomy that astronomers do likewise. This does not mean, of course, that professional historians, sociologists, political scientists, and specialists in other disciplines have nothing to contribute. On the contrary. All sciences, and especially medicine, have social, political, and other aspects that are to be studied, and, of course, the history of all sciences should be seen in their social and historical context. It means, however, that the history of medicine without physicians can only be partial and fragmentary. We have discussed above how misunderstandings about certain basic concepts underlying scientific medicine can arise in medical historiography when the scientific point of view is neglected. We must also remember that, after all, a rather important component of the history of medicine is medicine and that physicians know something about it. At the present time, because of the weaknesses of American education, ‘our great national failure’ (9). our schools do not prepare physicians to appreciate medical history let alone to contribute to medical historiography. This is, of course, a serious problem that cannot be discussed here. We can only hope (spes ultima &a) that it may be both solvable and temporary. References I. 2.
3. 4. 5.
6. I. 8. 9.
Prioreschi P. Does history of medicine teach useful lessons? Perspect Biol Med. In press. Hermann Baas 3. Outlines of the history of medicine and the medical profession. Transl by H E Handerson, Huntington, NY Robert E Krieger Publishing Co Inc. Reprint of the 1889 edition: i, 1971. Sigerist H E. A History of Medicine. New York and Oxford, Oxford University Press. 6, 1951. Nuland S B. Doctors and historians. J Hist Med Allied Sci 43: 137-140, 1988. Kaiser R M. Book review of .I K Aronson, An account of the foxglove and its medical uses 1785-1985. 1 Hist Med Allied Sci 43: 88. 1988. Unschuld P U. Medicine in China. A History of Ideas. Berkeley, University of California Press: p3, 1985. Gellius A. Noctes Atticae, X. x. Oppenheim A L. ‘Mesopotamian Medicine’, Bull Hist Med 36: 97-108, 1962. Jarcho S. Some observations and opinions on the present state of American medical historiography. J Hist Med AUied Sci 44: 288-290, 1989.
Medical Hypotheses
7
L
Mdc‘li Hypohws Q Longmtn Gmp
I
(1992) 38.97-101 UK Ltd 1992
Physicians,
Historians, and the History of Medicine
P. PRIORESCHI Creighton University 68 178, USA
School of Medicine,
Department
of Pharmacology,
California
at 24th Street, Omaha, NE
Abstract-For American medical historiography, to borrow from Dickens, these are the best of times and the worst of times. These are the times when rigorous scholarship has been brought to bear on the field (with great improvement in the quality of research) and when medicine is disappearing from its own history. These are the times when, in general, historians know only their field of specialization and physicians know only how to treat diseases. These are the times of focused competence and general ignorance. The history of medicine has become a field where historians write for other historians who, limited by their ignorance of medicine, cultivate mainly its sociological and political aspects. Physicians, on the other hand, are taught that only what is ‘relevant’ counts, and practise medicine in ignorance of their past because the history of medicine does not seem to have any immediate utility (1). The few among them who attempt to do something in what is, after all, the history of therr profession, are often considered, by historians, naive dabblers who tack knowledge and capacity for the task. This state of affairs came to be fairly recently. it began with a positive development in medical historiography: the realization that the history of medicine was not a discipline that helped to treat diseases but the history of one of man’s endeavours, in other words, that it was not a branch of medicine but of history.
The history of medicine as a branch of history
tinued to be regarded as of interest almost exclusively to the physician, who in turn considered it part of his medical knowledge. In other words, he considered the knowledge of Hippocrates and Galen useful to treat pneumonia and dislocated shoulders. Whereas what we today call basic sciences (anatomy, physiology, pharmacology) became sciences earlier, it was only in the second half of the 19th century that scientific clinical medicine began evolving to become eventually what it is today. This entailed a reassessment of the meaning and function of the his-
Until the beginning of the 19th century, Hippocratic medicine was still taught at the School of Medicine of the University of Paris and the medicine of the remote past was studied not as history, but as knowledge useful for the treatment of diseases. It is true that from the end of the 17th century to the end of the 18th, some histories of medicine were written (e.g. those of Le Clerc, of Friend and of Sprengel) that showed a trend toward a more historical interpretation, but, by and large, the history of medicine conDate received 17 June 19Y 1 Date accepted 30 September 1991
97
98 tory of medicine. But the process was slow. In 1889, Baas could still write: The history of medicine, of all the branches of that art, is the one to which least attention is devoted by physicians; and yet its study not only possesses great scientific value, but likewise includes an important germ of practical information (2)
He thought not only that the history of medicine was a branch of medicine but also that it was of interest to physicians because it still ‘included an important germ of practical information’. The times, however, were changing. Historiography in general had come of age, and scientific clinical medicine proceeded to build on the solid bases set by the scientific revolution in the previous centuries. The historiogmphy of medicine also had to undergo change. In the first half of the 20th century the first centers for the study of the history of medicine were founded in Europe (in 1905, at the University of Leipzig) and America (in 1929, at the Johns Hopkins University) but the discipline was still practised mostly by amateurs (usually physicians) although serious studies were becoming increasingly frequent. Slowly, its practice started to drift from physicians to professional historians. This trend was seen with some apprehension by the former although the importance of the contributions of historians and other non-medical professionals was well understood. Sigerist, a physician, in the introduction of his A History of Medicine wrote: It would be a mistake to assume that medical history today is a concern of historians and philologists alone and of no interest to physicians. Medical history is medicine also, today as it was in the past. We shall have to demonstrate this. Several generations of philologists and historians have made valuable contributions to the field. They did most of the spade work, made sources available, and, by looking at medicine from the outside, brought in interesting points of view. It seems to me, however, that today more than ever there is need also for medical interpretations and evaluations of the past of medicine (3).
This was in 1951. We are now close to the end of the 20th century and we have to conclude that the healthy process of evolution of medical historiography, as it passed from the hands of physician amateurs to those of historians and other non-medical professionals, has gone too far. There is no doubt that it was indeed necessary and beneficial that strict scholarly criteria be applied to medical historiography. Modern methods of social
MEDICAL HYPOTHESES
and historical analysis were brought to bear in this field as they were in other branches of historiography. The history of medicine ceased being exclusively a chronicle of discoveries and biographies of great physicians and became a study of the healing arts in the context of social, political, and cultuml changes. However this did not mean that physicians were no longer needed in medical historiography. Yet, the result was that they withdrew from the field. The history of medicine came to be perceived by the profession as an esoteric field, dangerous to tread, to be left to the specialist. In addition, the curriculum of the medical scientist became more and more technical and a humanistic education came to be seen as useless for the pursuit of a medical career. The physicians no longer learned Greek and Latin, no longer were familiar with philosophy and history, no longer were interested to know, in the words of Sigerist ‘what the Greeks, the Romans, the people of the Renaissance had done to protect and restore their health and what ideas had been guiding their actions’ (3). Ignorance of the history of their own discipline was the result. Nuland recently wrote: Today’sprofessors (of medicine) are no better equipped to speak of William Harvey, for example, than they are to quote Marcus Aurelius. The operating or rounding clinician who makes reference to a historical event is at best considered to be a raconteur of reconditeness; at worse (and I fear this is more often the case), he is seen as a harmless fogy whose recollections get in the way of the serious work at hand (4).
As physicians withdrew, medical historiography became more and more concerned with the non-medical aspects (especially the sociological and political ones) of the history of medicine and physicians who intruded in the field were increasingly resented. Again in the words of Nuland: Another of the major criticisms directed at the presentday profession of medical history is that it is largely a fraternity of scholars untrained and uninterested in clinical medicine, and sometimes antagonistic to its practitioners. Many of the issues with which it concerns itself are seen... as ‘medical history without medicine.’ This is a criticism that I think is valid, or at least valid enough that it must be addressed. Just as there are insights and interpretations that only a social and a cultural historian can bring to the study of medicine’s past, there are insights and interpretations, at least as signtficnt, that can only be supplied by men and women who are involved in the art and science of healing (4).
This is what the situation is today. Unfortunately, however, this hiatus between historians and physici-
PHYSICIANS. HISTORIANS AND THE HISTORY OF MEDICINJZ
an:; has had other unhappy consequences for medical historiography. Scientific ‘truth’ and scientific progress The withdrawal of the physicians, that is of the scien-
tists, from medical historiography has caused misconceptions about certain fundamental tenets of science and medicine among medical historians. Here are a few examples. In a book review we read: This chronological account is accurate, straightforward, and well written, but suffers from an overriding contemporary scientific bias... the book chronicles
the progressive accumulation of ‘correct’ knowledge a.bout digitalis, as the pathophysiologic perspective of 1’9th and 20th century physicians replaces the rather ‘primitive’ perspective of their forebears (S).
Obviously the reviewer is laboring under a non-scientific understanding of what scientific progress and truth are (see below). This makes him unaware of what should be evident: in view of the fact that today we know more about digitalis (in other words we have more accurate information concerning the actions of the drug) and therefore we can better use it to treat disease, why should we refrain from comparing our knowledge from that of our forefathers? Don’t we expect that those who will follow us will also compare our ‘primitive’ knowledge with their more advanced one? Is this not one of the raisons d’etre of the history of science? Another example: Topoint
out the fact that health care beliefs make sense
in the context of culture represented a significant step forward from earlier notions that discriminated only between truth, science, and rapidly advancing modern medicine, on the one hand, and false, irrational, and static beliefs, stubbornly adhered to by uneducated pr,imitives, on the other hand (6).
There is no question that health care beliefs make sense in the context of culture; there is no question that if this was not realized by previous historians it should have been; there is no question that the awareness of the importance of the cultural context represents, a significant step forward, but it should be obvious t.hat there is also no question that we must make a distinction between truth and science, on the one hand, and false beliefs on the other (the ‘irrational... static. .. stubbornly adhered to by uneducated primitives’ was added by the author simply for the sake of color, of course). Aulus Gellius (7) states that the
99 reason, given by Apion, for which the ancient Greeks and Romans wore a ring on the next-to-the-left little finger was that the Egyptians had found a very fine nerve going from that finger to the heart. Should we refrain from saying that this quaint notion, interesting as it may be, is anatomical nonsense? And another example: (One possibility would be) to label the Near Eastern scientific achievements as a ‘pre-scientific’ stage... However, such practices are so obviously ethnocentric and naively self-gratificatory that they cannot be accepted. They belittle the intellectual achievements of mature civilizations by a priori characterizing them as a preliminary phase, a preparatio Evangelli, which is to usher in one’s own civilization (8).
One would think as self-evident the fact that the use of the term ‘prescientific’ does not belittle anybody or any civilization. The expression simply recognizes that there are stages in human history and that as there was a ‘pre-industrial’ era so there was a ‘pre-scientitic’ one. Obviously there is nothing ‘ethnocentric and self-gratificatory’ in observing that our and other civilizations, at a certain time, were in the pre-industrial or pre-scientific stage (again, the ‘preparatio Evangelii’ is there for color). The last two quotations, like the first one, suggest that their authors have concepts concerning science, scientific progress and scientific truth that differ from those usually held by scientists. The origin of such concepts, which are so common in contemporary medical historiography, have their roots in problems of modem epistemology which have degenerated into a contemporary all-embracing relativism. In modem times, several philosophers (Locke, Berkeley, Hume, Fichte, Kant, Bradley) investigating the so-called ‘problem of knowledge’ have shown that a simple correspondence between sense data and reality could not easily be assumed. More recently, Heisenberg, a physicist, with his famous uncertainty principle, has shown that, at least at the subatomic level, physical reality may not be simultaneously knowable in all its aspects. This, of course, cast a shadow on the validity of our knowledge of the external world and, in turn, raised the question of the ‘relativity’ of scientific knowledge, that is to say, whether the natural laws that are the object of scientific knowledge do exist in themselves or if they are the creation of the human mind. In spite of all philosophical doubts, however, it is evident that the scientist must assume that there is a concrete knowable reality otherwise science and scientific research would not exist: only if Parkinson’s disease has a knowable pathogenetic mechanism, can
100 we hope to find it; only if black holes are regulated by laws that are knowable does it make sense to seek them. As a consequence, scientists conduct their research as if there were a perfect correspondence between sense-data and reality and assume that there is a natural ‘truth’ that they are striving to discover. What we call ‘science’, in fact, is the ongoing progressive process of discovering such ‘truth’. The process brings us closer and closer to the goal even if, it is assumed, never quite up to it (as if it followed an asymptotic curve). For this reason any accepted scientific explanation is considered a temporary hypothesis ready to be replaced by another that is closer to the ‘truth’. This, of course, constitutes what we call scientific progress. This being the case, two consequences, which are of importance in any discussion of the history of medicine and of science in general, result. The first one is that contradictory explanations of natural phenomena cannot be equally valid and, therefore, one has to be better than (that is, superior to) the other (e.g. the Ptolemaic and Copemican paradigms cannot both be equally good explanations of the solar system; the pathogeneses of pneumonia according to modem medicine and to traditional Chinese medicine cannot both be correct). One is superior to the other for theoretical reasons (one is ‘truer’ than the other) and often for practical reasons as well (the Copemican system better explains the observed phenomena; modem ideas of the pathogenesis of pneumonia allow us to better understand the morbid process and, consequently, to devise a more effective treatment). The condemnation and indignation expressed in the quotations above about lamentable ‘contemporary scientific bias’ and about the wrongness of thinking that many scientific beliefs of primitive people were false are therefore unwarranted. The second point is that, in the pursuit of scientific knowledge we must use the tool that is most apt to further such knowledge. Experience has shown that, so far, the scientific method (which is defined as the collection of data through observation, the formulation of hypotheses, and the confirmation of the hypotheses by experimentation) is such a tool. It is evident, however, that there is nothing inherently sacred about the scientific method. Obviously, if somebody were to find out that after meditating (or drinking a certain potion) one would acquire new insight into the laws of nature, i.e. if the meditation (or the potion) would reveal to us a better cancer therapy or give us a new insight into the structure of Halley’s comet, then the scientific method would
MEDICAL HYPOTHESES
have to be discarded in favor of meditation (or potion drinking). So far, however, this has not happened. The scientific method seems to be, by far, the best tool for acquiring new scientific knowledge although the latter may also be obtained by other means (e.g. trial and error, intuition). For this reason it is entirely correct to assert that, as far as science is concerned, any society in the ‘scientific stage’ is more advanced than one in which the scientific method was (or is) not applied, that is, than any society in the ‘pre-scientific stage’. In view of the above, should we consider scientific medicine the standard against which all other medicines are measured? Of course we should. In the same way as scientific physics is the bench mark against which all beliefs concerning physical phenomena are to be measured. This is because scientific knowledge is the closest to the natural ‘truth’ discussed before. It is evident then that, for this reason, some ancient scientific ideas were wrong (‘false’ or less ‘true’ than ours) and that it would be absurd not to say so. It would appear that the beliefs quoted above concerning scientific truth and scientific progress, and other similar beliefs so common in contemporary medical historiography, are due to their holder’s lack of experience in science and, in some cases, to their training in history and/or philosophy. Such training would naturally predispose them to emphasize philosophical doubts and to neglect the scientific point of view. In addition, those doubts would tend to reinforce the inane relativism, so common in contemporary thought, according to which all opinions, all beliefs, all behaviors, all vices, all virtues, have equal validity. We have seen that science, from this point of view, is the antithesis of relativism because, contrary to it, it establishes hierarchies of validity, it strives to find what is better and what is worse , what is superior and what is inferior, what is valid and what is not. As noted above, not all scientific views, ideas, and opinions can be equally valid: when two oppose each other, one is usually closer to the ‘truth’ and therefore superior to the other, that is, better than it. Historians and historian physicians
It is not hard to detect a degree of resentment on the part of professional historians (even of those who are not ‘new-wave’) toward those physicians who dare to enter the field of the history of medicine without formal training. A common utterance heard in defence of such attitude is ‘How would you feel if a historian were to practice medicine without training?‘. The
PHYSICIANS,
HISTORIANS
101
AND THE HISTORY OF MEDICINE
point is, of course, invalid. It is invalid because of an asymmetry that exists between science and the humanities, the same asymmetry that allows a physicist to be a poet but forbids a poet to be a physicist. It is evident that a poet cannot, without training in the field, be a physicist because physics has such a high degree of esoterism that only a specialist can master it. The degree of esoterism can be operationally defined as the inverse of the extent to which a certain discipline or field may be familiar and explored by the educated non-specialist. For example, we all can (and often do) read (and sometimes even writ.e!) poetry, history, or literature and some of us, without formal training in the field, may be familiar with the poetry of Petrarch and the history of the French Revolution and be quite knowledgeable about the works of Tolstoy. On the other hand, how many of us non-specialists read (let alone write) works on nucl.ear physics or are familiar with the UhlembeckGotidsmit theory and are knowledgeable about the Pauli exclusion principle or the SchrMinger wave equation? It is conceivable that a physician, untrained as a poet, could write poetry because, although the writing of poetry requires many qualities and capabilities, it has a low degree of esoterism. This, of course, does not mean that physics is more difficult than poetry. Not at all. In fact, good poets are rarer than good physicists. It simply means that whereas a physicist without any particular training in poetry could write a good poem, or even be a good poet, a poet without training in physics could not be a physicist, let alone a good physicist. Olbviously this applies not only to poetry and physics, but to all human intellectual endeavors. The degree of esoterism of each endeavor or discipline cannot be objectively measured, it can only be assessed through operational evidence: the fact that someone without specific training could write a novel but not be a physicist indicates that literature has a low degree of esoterism and physics a high one. What about other disciplines? All have different degrees of esoterism that can be roughly assessed only by comparison. If we consider poetry and physics as the two ends of the spectrum, it would appear that, for example, literature, history, sociology, medicine, and chemistry would fall in between, more or less in that order. It stands to reason: if we were to hear that a certain expert on Dante or on the Thirty Years War had no formal training in literature or in history, we would not be terribly astonished, but it would be astonishing inded if a professor of Latin literature, with no training in medicine, was an expert neurosurgeon.
It is, of course, because of this asymmetry between science and the humanities that a physician without formal training in historiography could be a historian (especially a medical historian) but not vice-versa. Once this point is clarified, we must address the question: how important is it that physicians contribute to medical historiography? It is essential. In the same way that it is essential for the historiography of mathematics that mathematicians contribute to it, and for the historiography of astronomy that astronomers do likewise. This does not mean, of course, that professional historians, sociologists, political scientists, and specialists in other disciplines have nothing to contribute. On the contrary. All sciences, and especially medicine, have social, political, and other aspects that are to be studied, and, of course, the history of all sciences should be seen in their social and historical context. It means, however, that the history of medicine without physicians can only be partial and fragmentary. We have discussed above how misunderstandings about certain basic concepts underlying scientific medicine can arise in medical historiography when the scientific point of view is neglected. We must also remember that, after all, a rather important component of the history of medicine is medicine and that physicians know something about it. At the present time, because of the weaknesses of American education, ‘our great national failure’ (9). our schools do not prepare physicians to appreciate medical history let alone to contribute to medical historiography. This is, of course, a serious problem that cannot be discussed here. We can only hope (spes ultima &a) that it may be both solvable and temporary. References I. 2.
3. 4. 5.
6. I. 8. 9.
Prioreschi P. Does history of medicine teach useful lessons? Perspect Biol Med. In press. Hermann Baas 3. Outlines of the history of medicine and the medical profession. Transl by H E Handerson, Huntington, NY Robert E Krieger Publishing Co Inc. Reprint of the 1889 edition: i, 1971. Sigerist H E. A History of Medicine. New York and Oxford, Oxford University Press. 6, 1951. Nuland S B. Doctors and historians. J Hist Med Allied Sci 43: 137-140, 1988. Kaiser R M. Book review of .I K Aronson, An account of the foxglove and its medical uses 1785-1985. 1 Hist Med Allied Sci 43: 88. 1988. Unschuld P U. Medicine in China. A History of Ideas. Berkeley, University of California Press: p3, 1985. Gellius A. Noctes Atticae, X. x. Oppenheim A L. ‘Mesopotamian Medicine’, Bull Hist Med 36: 97-108, 1962. Jarcho S. Some observations and opinions on the present state of American medical historiography. J Hist Med AUied Sci 44: 288-290, 1989.
