The Rise of Causal Concepts of Disease: Case Histories (review)

Codell Carter here sets out a revisionist history of nineteenth-century medicine, in which he directly or indirectly attacks almost all received accounts and approaches. His main claim is that in highlighting such developments as pathological anatomy, physiology, and bacteriology, historians have missed the single most important project of the age: the search for universal necessary causes of disease. Methodologically, he criticizes historians for concentrating on empirical discoveries and professional developments, and neglecting the development of medical theory. It is great to have such a challenge, not least because much history of medicine avoids methodological issues and large problems.

Carter's approach is based upon the ideas of two philosophers—Karl Popper and Imre Lakatos—who were influential in the 1960s in major debates with Thomas Kuhn over the history and philosophy of science. As is well known, it was the work of Kuhn that went on to influence the history of science, with the influence of Popper and Lakatos waning in the 1970s. In reviving these long-unfashionable ideas, Carter is also reopening questions about the nature of "rationality" and its place in historical analyses of science and medicine. Indeed, an unacknowledged theme in Carter's case histories is that the best medicine was (and should be studied by historians as) a "science." While he takes from Popper the overarching importance of theory and hypotheses (such as that all diseases have universal necessary causes), it is from Lakatos that he takes his main organizing concept—the research program, "a temporally continuous cooperative endeavour" (p. 4) that "consists of (mostly implicit) methodological rules" and a framework of ideas (p. 3). Although shifts in ideas and methods around germ theories of disease and bacteriology loom large in the book, Carter is at pains to stress that these were part of a broader movement in ideas in which disease was thought about causally in rigorous (i.e., rational) ways. He follows the progressive development of causal thinking from early nineteenth-century studies of parasites through to Freud's work on neuroses. The heroes of this book all contributed to what Carter claims, quoting F. Kräupl Taylor, has been "the final hope and aim of medical science . . . the establishment of monogenic disease entities" (p. 197).

So, where stands the history of nineteenth-century medicine in the light of Carter's assault? Is he correct that most historians have missed its single most important development and the defining feature of modern medicine? Well, in my view there is no need to throw away standard texts or rewrite syllabi: Carter's account is open to the same objections that led historians of science a quarter of a century ago to reject Lakatosian "research programs" as heuristically useful. The whole approach relies upon the reconstruction of ideas by the philosopher-historian into an asocial "third world" of rational thought. This leads to a blinkered and judgmental approach that focuses on the work of those who followed the progressive rational program and that neglects alternative rationalities and ideas.

Carter is concerned with the development of medicine as a science—indeed, a particular "rational system" of thinking about disease causally. Of course, throughout the nineteenth century doctors were divided over whether medicine should aspire to become a "science," and, if their enterprise was to be "scientific," what type of science it should be. While Carter perceptively traces changes in the types of etiological thinking across the century, his approach obscures the key point—namely, that clinicians and emergent medical scientists were uninterested in etiology for much of the century: their interests lay in nosology, diagnosis, pathology, prognosis and therapeutics. Moreover, when clinicians did think causally—say with tuberculosis after the announcement of the tubercle bacillus in 1882—it was less in terms of the necessary causal organism, whose presence they could do nothing about, and more in terms of the predisposing conditions and ancillary causes that they might be...