Writings on Medicine

1. The Idea of Nature in Medical Theory and Practice

o n e The Idea of Nature in Medical Theory and Practice One may wonder whether the doctor-patient relationship has ever succeeded in being a simple, instrumental relation that could be described in such a way that the cause and the effect, the therapeutic gesture and its result, would be directly related one to the other, on the same plane and at the same level, without being mediated by something foreign to its space of intelligibility. It is certain, in any case, that the centuries-old invocation of a healing nature [une nature médicatrice] has been and remains the reference to just such a mediator, who would account, throughout history, for the fact that the doctor-patient couple has only seldom been a harmonious one, in which each partner can be said to be fully satisfied with the other’s behavior. To procure, for the sick man, by efficacious interventions, an amelioration or a restitution that he would not know how to obtain by his own means: that is the doctor’s ambition, an ambition that is not ruled out by his sincere and persistent abstention from all charlatanism but is merely the other side of his professional honesty. This ambition may even contain the 25 26 The Idea of Nature idea that a sick organism is, vis-à-vis the doctor and for him, nothing more that an object that is passive and obedient to external manipulations and solicitations. John Brown, a Scottish doctor much celebrated in Italy and in Germany at the beginning of the nineteenth century and the inventor of the concepts of stenia and asthenia,1 believed it possible to summarize succinctly the imperative of medical activity: ‘‘In order to both prevent and cure diseases, we must always use the indication proposed, and stimulate or debilitate; never wait, nor trust the supposed powers of nature, which have no real existence.’’2 This was the necessary consequence of a certain conception of the living body: ‘‘Life is not a natural, but a forced state . . . kept . . . not by any powers in themselves, but by foreign powers.’’3 For an inert body, an active medicine. Conversely, an awareness of the limits of the power of medicine accompanies any conception of the living body that attributes to it, in whatever form, a spontaneous capacity of conserving its structure and regulating its functions. If the organism has its own capacities of defense, then to trust it (at least temporarily) is a hypothetical imperative for both prudence and skill. For a dynamic body, an expectant, passive medicine [médecine expectante ].4 Patience—a wait-and-see attitude—would thus be the spirit [génie] of medicine. And still it would be necessary for the patient to agree to this forbearance. Théophile de Bordeu observed and wrote of this very well: ‘‘this expectant method has something cold or austere to it, and the vivacity of patients and assistants need not adapt to it. Also, those who employ it have always made up only a small number of the doctors, especially among people who are naturally sharp, impatient, and apprehensive.’’5 Not all treated patients heal. Some patients heal without a doctor. Hippocrates , who consigns such remarks to his treatise The Art, also holds the responsibility for—or the legendary glory of—having introduced the concept of nature into medical thought.6 ‘‘Nature is the doctor of disease.’’7 By ‘‘doctor,’’ we should understand an activity, immanent to the organism, that compensates for deficiencies, reestablishes disruptions of the equilibrium, and corrects the bearing [allure] when it detects a change. This activity is not a thanks to a natural intelligence [science infuse]: ‘‘nature finds the ways and means by herself, not by way of intelligence: for example, blinking and the tongue offer assistance, as do other actions of this kind; without instruction or knowledge, nature does what is appropriate.’’8 The Idea of Nature 27 The analogy between the art of the doctor and healing nature does not elucidate nature through art, but art through nature. The medical art must observe, must listen to nature. Here, to observe and listen is to obey. Galen, who attributed concepts one can call merely ‘‘Hippocratic’’ to Hippocrates himself, also took them up as his own: he, too, taught that nature is the first to conserve health because it is the first to form the organism. One must remember, however, that...