Crossing the Bridge
Toward an Applied History of Medicine

By Howard I. Kushner, Nat C. Robertson Professor of Science and Society, Department of Behavioral Science and Health Education, Public Health, and Graduate Institute of the Liberal Arts

Return to Contents

I hold a joint appointment at the School of Public Health and Emory College. My departmental homes are literally separated by a railway bridge; daily I must decide which side of the tracks to inhabit. My departments have very different academic missions. Behavioral Science and Health Education teaches its students how to develop interventions to improve population health, while in the Graduate Institute of the Liberal Arts my teaching has a more theoretical focus.

This may seem like a predisposing path for an academic identity crisis, if not multiple personality disorder. When asked the inevitable disciplinary question, “What are you?,” I hesitate, trying to articulate an authentic response. The short answer is that I am an applied historian of medicine. I am committed to the proposition that medical knowledge must be placed in historical and cultural perspective, but I am also persuaded that historical findings can be applied as clues for solving current medical mysteries.

An applied history of medicine requires interdisciplinary collaboration and a shared understanding among team members of the contributions of the various disciplinary fields. While such collaborations have become more common within medicine—for instance, among clinicians with different specialization—and across the sciences, the inclusion of social scientists and humanists is less common. It is rarer still among historians. One reason for this is historians’ preference for solitary research; another is the lack of professional incentives and rewards for collaboration.

Until the 1970s there were very few academics who considered themselves historians of medicine. Those who called themselves
medical historians most often were clinicians with an interest in advances in medical knowledge and clinical practice. Their focus was on producing narratives of medical “progress,” often uniformed by the methods and practices of professional historians. Consequently, these physician-medical historians tended to ignore the social and cultural context in which developments in medicine took place. Their explanations increasingly became the target of a new generation of professional historians who attempted to contextualize the history of clinical diagnoses, disease classification, and medical interventions. These scholars rightly insisted that the production of scientific knowledge is framed by political, intellectual, and cultural constraints. Their revisionist history portrayed medical practice, research, and innovation as cultural constructs whose scientific claims resembled belief systems. If science were no different from other belief systems, it often seemed pointless to learn
its mechanisms.

Medical practitioners and laboratory scientists, often baffled by the vocabulary of much of this new history of medicine, found it difficult to recognize its value for research and practice. In contrast, the cultural historians of medicine, recalling the uncritical narratives of their predecessors, frequently expressed reservations about the activities of colleagues who engaged in applied and collaborative research. They particularly distrusted studies that relied on current understandings of disease mechanisms to explain earlier disease incarnations. As a result, the application of historical findings to current clinical issues and medical research became suspect, if not illegitimate.

In the 1990s, a new generation of applied historians of medicine, often trained in both medicine and history, emerged. Given their dual education, they were forced to confront a contradiction: one discipline had taught them that applied research was suspect, while the other expected them to develop effective interventions. Moreover, the dominant view in medicine remained that, although history was interesting, its utility was didactic, to remind practitioners of past successes and failures. Because they felt comfortable in both disciplines (or equally uncomfortable in either) these new medical historians challenged the dominant paradigm generally by ignoring it. Most of all, they were persuaded that
medical research uniformed by historical context could be as
incomplete as an investigation of chronic disease that ignored genetics or immunology. Their approach to the history of medicine has been increasingly recognized and encouraged at research universities with health sciences centers.

Because I am most familiar with it, I draw on some of my own experience to illustrate what applied historians of medicine actually do. Recently, I have been a member of interdisciplinary teams engaged in developing new hypotheses for two very different syndromes. The first, Tourette syndrome, deals with the head, while the second, Kawasaki disease, is a matter of the heart.
This work has been supported by a series of collaborative grants from federal, state, and private agencies, and the results of these collaborations have appeared in medical and history journals.
In the mid-1990s I was invited to join a neuro-psychiatric pediatric clinical team at Brown University investigating the etiology of Tourette syndrome (TS), a disorder in which the afflicted display an array of motor tics and involuntary vocalizations. My colleagues were particularly intrigued by my investigation of patient records and medical reports since the 1820s that had revealed that patients often reported an episode of rheumatic fever preceding the onset of TS. This meshed with their clinical observations that a significant number of TS patients displayed an exacerbation of tics and vocalizations following infection by rheumatic streptococcus.

Until the mid-twentieth century, no one understood the infectious and post-infectious cascade that resulted in rheumatic fever, let alone the possible link between a bacterial infection and a psychiatric presentation. Thus, the association between TS and rheumatic fever was noted, but ignored, by most investigators for the past two centuries. An illness called Sydenham’s chorea, however, was a common sequel to rheumatic fever. Patients with this condition display tics and vocalizations similar, but not identical, to TS.

Although neurological and psychiatric residents are taught to distinguish between TS and Sydenham’s on the basis of the differences in presenting signs, our history and clinical experience suggested that there was no compelling reason to exclude common predisposing mechanisms. TS and chorea could have similar causes but slightly different presentations due to host differences or to the developmental stage at the time of an insult. Thus, we hypothesized that antibodies to the bacterial infection created lesions in brain tissue (in the circuitry of the basal ganglia), which resulted in tics and vocalizations. Our team and others at nimh conducted a series of laboratory tests and developed animal studies that indicated that in some patients, antibodies to rheumatic streptococcus were most likely a predisposing factor. This finding has led to new diagnostic tests and experimental treatments for a sub-set of TS patients. Although these investigations are ongoing, most TS researchers now acknowledge that infection is likely an important environmental trigger to some of what we label TS.

The second example involves changing the diagnostic criteria for Kawasaki disease (KD), an elusive rash and fever illness of early childhood, first identified by a Tokyo pediatrician in the mid-1960s. Though generally benign and treatable with a timely diagnosis, coronary artery aneurysms (CAA), sometimes fatal, may develop in up to 25 percent of untreated children. Because the etiology and mechanisms of KD are unknown, diagnosis, as with TS, is made by relying on a list of clinical signs. Our retrospective historical epidemiology, when combined with our prospective study of patients admitted to San Diego hospitals from 1998 to 2002, revealed that a significant number of children fail to meet the clinical criteria, receive delayed treatment, and develop CAA. We hypothesized that the there might be a connection between these missed cases and the continuing frustration of researchers to identify the etiological agent(s) and mechanisms responsible for CAA. In order to determine what that connection might be, we launched a historical investigation into the construction of the clinical diagnostic criteria for KD. We explored how the construction and reification of the KD diagnostic criteria influenced the framing of research questions.

By demonstrating that the KD case definition was constructed in response to particular political and cultural circumstances, rather than from robust scientific evidence, we were able to persuade clinicians to rethink their diagnostic criteria and to be sensitive to atypical presentations that might actually be at a greater risk for development of caa than patients who meet the specific criteria. Our collaborative investigation demonstrates how a historical analysis can lead to the development of a more inclusive protocol for research on its etiology and patho-physiology. In a recent article in Perspectives in Biology and Medicine, we have made several specific suggestions for developing this protocol, some of which have been adopted by the American Heart Association and appear in the 2003 revision of the Redbook, the primary pediatric diagnostic handbook.

Although clinical concerns prompted both the TS and KD investigations, they nevertheless have important implications for the development of an applied history of medicine. On the one hand, such investigations provide an illustration of how a historical interrogation of syndrome construction can free medical researchers to pursue alternative and novel approaches. On the other hand, they demonstrate how historians can make unique contributions as collaborators in clinical care and medical research. Historical investigations of syndrome construction can elicit useful issues
for the development of research hypotheses and clinical diagnoses. In this way, applied historians of medicine can become important partners in collaborative interdisciplinary medical research.

One of the unique features of Emory is the close proximity of the arts and sciences, the health sciences, and the other professional schools on one campus. This geographical location has resulted in numerous collaborations. While many of these remain informal, others—such as the Center for Health, Culture and Society—are somewhat more institutionalized. The former director of the center, Randall Packard, was a historian of medicine, and under his tenure the center organized interdisciplinary symposia on topics such as emerging infectious diseases and, along with Emory’s program in Science and Society (led by biologist Arri Eisen), seminars on addiction, race and disease, and culture and medicine. When Packard left to head the history of medicine program at Hopkins, the leadership of the chcs was taken over by a medical anthropologist, Peter Brown, and a historian of medicine, myself. We continue to facilitate interdisciplinary training and collaborations to investigate medical mysteries such as infectious and chronic diseases. We also hope many others at Emory will be persuaded to cross the bridge more often.