Clinics in Dermatology (2014) 32, 170–173
CLIO DERMATOLOGICA Edited by Mauricio Goihman-Yahr, MD, PhD
History, dermatology, and medicine: Another outlook☆,☆☆ Mauricio Goihman-Yahr, MD, PhD ⁎ Professor of Dermatology and Immunology (E), Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela
Abstract The History of Medicine and of Dermatology tends to analyze what happened in these disciplines in a given time and place. Contributions of relevant leaders are studied carefully, and their appropriate value to knowledge is determined. This is fundamental to understanding present knowledge and what might be expected in the future. There is, yet, an additional perspective, namely, the relationships between the above and historical phenomena in their wider sense; particularly, the correlation between politics, economy, psychohistory, and medicine. Evolution of medical knowledge does not occur in a vacuum. This contribution provides examples of this viewpoint and how knowledge of history makes clearer the development of medicine and vice versa. Emphasis is also made on the history and development of dermatology, but rather as an illustration of the overall philosophical point of view of the writer than as an analysis of the history of dermatology in itself. One may summarize metaphorically this viewpoint by stating that while the microscope and the dermatoscope are very important, the telescope is vital for integral knowledge. © 2014 Elsevier Inc. All rights reserved.
Introduction History is what basically differentiates a discipline from a trade and a specialty from a skill. ☆ Disclaimer: This manuscript expresses the opinions of the author. It does not present nor does it purport to present the points of view of the Central University of Venezuela, or of any of its Schools or Departments. The matter covered has been used for two oral presentations under similar names:
1. At the meeting of the Society for the History of Dermatology in San Diego, California in 2012 (parallel with the 70th meeting of the American Academy of Dermatology). 2. At a session of the Academia Nacional de Medicine, Caracas later the same year. The two presentations were not identical and the current contribution is different, although very much related to both. ☆☆ Presented in part at the History of Dermatology Society Seminar, March 15, 2012, San Diego, CA, at a session of the Academia Nacional de Medicina, Caracas, Venezuela, xxx, 2012. ⁎ Corresponding author. Fax: 58 212 7308861. E-mail address: [email protected]. 0738-081X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clindermatol.2013.08.021
Whatever happened? Who intervened in important events? What is the legacy that was left? These are the basic questions posed by the history of medicine and of dermatology. The study of both documents and archives and of oral tradition allows us to preserve pertinent knowledge and to answer the questions just mentioned above. In this way, we can understand how medicine and its specialties were formed and their respective definitions, rules, and regulations promulgated. There is much more. How does medicine or dermatology relate with the national or international historical phenomena? How do world currents of opinion, plus geographic and economic factors, interact? How is it that selected individuals may seem to lead history at certain times? How does history lead individuals most of the time? Modern science has discovered new revolutionary techniques. How can these be applied to medical historical knowledge? This contribution illustrates some examples of what has been outlined in the paragraphs above.
History, dermatology, and medicine: Another outlook
The other vision New technology New technology has revolutionized and will continue to revolutionize historical analysis. A small disc may include all human populations that have existed from 3200 BCE to 2009 CE as shown in a contest of photographic images shown in Science in 2011.1 In the figure, even losses by war and epidemics are shown in blank spaces. Academic life consists in great part of the analysis and assimilation of knowledge through texts. This effort can nowadays advance exponentially by means of quantitative analysis of digitalized texts. This permits a deep and, at the same time, extensive view of the fundamentals of scientific, medical, or literary culture. It also allows the possibility of integrating knowledge in a nontheological Summa. The term that has been used is that of “culturomics.” It is most tellingly told in reference2 that covers this subject and comes from a journal, such as Science.
The rule of just laws Organized societies need effort, goodwill, and a just or at least acceptable, legal structure to maintain themselves. When this structure is broken, societies dissolve themselves, and results are evident and showy. Spengler cites the writings of an Egyptian prophet who tells what happened in his country when the Middle Empire fell in the 17th century BCE:3 The High Officials have been deposed, the country has been deprived of its monarchy by a few fools and the counselors of the old state court to the upstarts. Administration has ceased and documents have been destroyed. All social distinctions have been suppressed and the courts of law have fallen in the hands of the mobs.
The quote continues afterwards: Theft and Murder reign, cities are deserted, public buildings are being burnt. Harvests dwindle … no one thinks about cleanliness …
I do not think that I am wrong when I suppose that many of the readers, including myself, do not find this description to be strange or distant. There is no need to go back that far in time. What happened in Hitler’s Germany was not very different from what was told by the Egyptian prophet. How did this influence dermatology?4 In less than a decade (1932-1940), the number of dermatologists in Germany dropped precipitously due to death (including suicide and prison)
171 and migration. Figures would even be more striking, if the period analyzed would be prolonged to 1945. Dermatologists and physicians of all kinds left Germany and spread throughout the four corners of the world. 4 German medicine in general and dermatology in particular was at the top up to the 1920s. Their full recovery to their former place has not happened yet, nearly 70 years after the fall of Hitler; yet, the disgrace of some is the benefit of others. United States´ medicine, as well as Brazilian, Turkish, South African, British, Israeli, and even Venezuelan medicine, benefited from the seeds dispersed by the rotting German fruit. The best parallel of the mixture of the tragic and irreparable with what becomes fertilizing is perhaps the fall of Constantinople. The latter lead to the beginnings of the Renaissance and the scientific explosion in Italy, from Leonardo to Vesalius.
The Janus face of migration We have already noted that migration, vis á vis tyranny, war, poverty (even newly emerged poverty), and social decomposition, is painful but might be saving and fertilizing. The examples shown indicate a flow from old civilizations to new or unrefined societies. There is also a migration of the reverse sign. This migration goes from new or underdeveloped countries to cultured and prosperous societies. In the case of medicine and other sciences, it is common to speak of “brain drain.” There have been efforts to block that flow by means of rather absurd notions of “justice” that do not resist an objective analysis; still, the brain drain is or might be a real problem and has valid solutions. The latter do not include the building of barriers and the prohibition of exit or entrance of persons that only wish to develop themselves and to contribute to their well-being, as well as that of societies that are able to use them appropriately. The solution lies in providing at the birthplace of physicians and scientists conditions such that would allow them to carry out respectable and beneficial tasks. This should be done by societies and mostly governments. Such an initiative took place in Mali as shown in reference. 5 I do not know whether recent turmoil in Mali has damaged this initiative. Venezuela, created in the early 1960s and 1970s, two institutions that served the purpose outlined above: the Venezuelan Institute of Scientific Investigation (IVIC) and the National Council of Scientific and Technological Research (CONICIT). The former is still working today, while the latter has been dismantled in the 21st century. About two years ago, I published a paper called “On Potted Palms.”6 Two potted royal palms, languishing in the narrow confines of their respective pots, were able to grow when transplanted to appropriate soil; thus, physicians and scientists need an appropriate soil to grow and reach the size of which they are capable. If they are confined to narrow places that oppress and limit them as
172 the ancient reducing shoes of Chinese ladies, they shrink and deform.
The roles of open economy and culture Scientific evolution of countries depends on conditions of their culture and their economy. A comparison between three countries, Germany, Turkey, and Egypt, was published in Science,7 but why these three countries? Partially, due to the great interest that there has been in the evolution of Egypt after the so-called Arab Spring; however, mostly, because neither Egypt nor Germany or Turkey are common countries. In addition, there are features in their respective histories that justify comparisons. Egypt is the country that has been at the forefront of advances in culture, science, and technology for the longest time in history. Six thousand years ago, it already had an organized civilization. Thirty-five hundred years ago, it recovered from the disaster described at the beginning of this contribution and played a leading role in the struggle of midEastern empires. Twenty-two hundred years ago, it had the best medical school of the world, that at Alexandria. A thousand years ago, Egypt had the largest hospital in the world. Turkey was the most powerful world empire up to 300 years ago and was a considerable world power until the end of World War I. Its shipping industry and its maps were at one time unsurpassed. Germany was restructured 143 years ago, and in 20 years, it was at the head of the world, at least in science, medicine, and social security. After the catastrophe of two world wars and under United States protection, Germany recovered a great deal of its scientific and technological capacities. In two decades, it also rehabilitated its unfortunate half that had been under the communist yoke for 50 years. Germany has shown clearly that science and knowledge progress under the aegis of freedom and order. Turkey, after the downfall of 1918, accepted under Kemal Atatürk a modicum of freedom and a lay system. This plus the influence of German migrants (many Jewish) and of the United States has allowed Turkey to reach an intermediate status both economically and in scientific production. The same has not happened to Egypt until now. The publication in Science 7 was optimistic in that a new day was approaching for Egyptian science. Events since then underline again the overwhelming importance of politics in the development and wellbeing of scientific endeavors. In June 2011, Egyptian Nobel Laureate Ahmed Zewail spoke at or near Tahrir Square about his plans for a “Cairo Caltech.”7 I am sure that current speeches at Tahrir Square are regrettably not about institutes for science and technology. There is a need to address specifically the issue of simultaneously analyzing and understanding scientific, public health, and medical care and politics. This was done in reference to Brazil in the Lancet.8,9 Brazil is a country that
M. Goihman-Yahr has always had a future but has been desperately looking for a present. It may be that the latter is taking shape nowadays. In the papers cited, authors underlined the system of communicating vessels that exist between legal, political, medical, and scientific factors. Just as an example, in the period that had been characterized as “democratic instability,” (1945-1964) the macroeconomic and socioeconomic context concerned import substitution, ie, urbanization, and penetration by foreign capital. The political character was that of liberal populist governments. The health system featured the establishment of the First Ministry of Health (1953), with emergence of a private business sector in health and laws that unified social security rights of urban workers (1960). Key health challenges were the emergence of “modern diseases” (eg, chronic degenerative diseases, as well as labor and traffic accidents). Very recent developments in democracy since 1988 have been in an upward line. A note of caution that I, as a Venezuelan, would like to make is that upward lines are not always persistent. In Venezuela, advances made in Brazil in the last two decades or so, were made back in the 1940s to the 1970s. In Venezuela, the upward line started to change its slope in the early 1980s and it went into a steep decline starting in or around the year 2000.
The take-home message The end message of this contribution is well illustrated in the front page of an issue of Science.10 The spacecraft Rosetta visited, photographed, and analyzed asteroid 21 Lutetia, a remnant planetesimal from the early solar system. Besides the significance of the names involved, this also shows the need that we, dermatologists immersed most of the time in details (using the microscope and the dermatoscope), should also look outwards using the telescope and the space-probe to understand, within the possible, the image of the whole.
References 1. Crnokrak P. Everyone ever in the world. Visualization Challenge (Honorable Mention). Science. 2011;331:851. 2. Michel JB, Shen YK, Presser Aiden A, et al. Quantitative analysis of culture using millions of digitized books. Science. 2011;331: 176-182. 3. Spengler O. The Decline of the West (translated into Spanish) EspasaCalpe, Madrid, 1958, Volume II p 499. (The citation was translated into English for this article by M Goihman.). 4. Scholz A. The decline of dermatology during national socialism. In: Scholz A., Holubar K, Burg G., et al. eds. History of German Language Dermatology. Germany: Wiley-Blackwell, 2009. pp 96-138 (parallel texts in German and English). 5. Taylor DA. News Focus Profile: Ogobara Doumbo. Mali researcher shows how to reverse brain drain. Science. 2011;332:1498-1499.
History, dermatology, and medicine: Another outlook 6. Goihman-Yahr M. On potted palms. Dermatol Online J. 2011; 17(6):14. 7. Lawler A. News Focus. A new day for Egyptian science? Science. 2011l333:278-284. 8. Paim j, Travassos C, Almeida C, et al. Health in Brazil 1.—The Brazilian health system: History, advances and challenges. Lancet. 2011;377:1778-1797.
173 9. Victora CG, Barreto ML, Leal M, do C, et al. Health in Brazil 6.— Health conditions and health-policy innovations in Brazil: The way forward. Lancet. 2011;377:2042-2053. 10. Sierks H, Lamy P, Barbieri C, et al. Images of Asteroid 21, Lutetia: A remnant planetesimal from the early solar system. Science. 2011;334: 487-490. (The figure alluded to appeared on the front page the corresponding issue [October 28, 2011] of Science.)
CLIO DERMATOLOGICA Edited by Mauricio Goihman-Yahr, MD, PhD
History, dermatology, and medicine: Another outlook☆,☆☆ Mauricio Goihman-Yahr, MD, PhD ⁎ Professor of Dermatology and Immunology (E), Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela
Abstract The History of Medicine and of Dermatology tends to analyze what happened in these disciplines in a given time and place. Contributions of relevant leaders are studied carefully, and their appropriate value to knowledge is determined. This is fundamental to understanding present knowledge and what might be expected in the future. There is, yet, an additional perspective, namely, the relationships between the above and historical phenomena in their wider sense; particularly, the correlation between politics, economy, psychohistory, and medicine. Evolution of medical knowledge does not occur in a vacuum. This contribution provides examples of this viewpoint and how knowledge of history makes clearer the development of medicine and vice versa. Emphasis is also made on the history and development of dermatology, but rather as an illustration of the overall philosophical point of view of the writer than as an analysis of the history of dermatology in itself. One may summarize metaphorically this viewpoint by stating that while the microscope and the dermatoscope are very important, the telescope is vital for integral knowledge. © 2014 Elsevier Inc. All rights reserved.
Introduction History is what basically differentiates a discipline from a trade and a specialty from a skill. ☆ Disclaimer: This manuscript expresses the opinions of the author. It does not present nor does it purport to present the points of view of the Central University of Venezuela, or of any of its Schools or Departments. The matter covered has been used for two oral presentations under similar names:
1. At the meeting of the Society for the History of Dermatology in San Diego, California in 2012 (parallel with the 70th meeting of the American Academy of Dermatology). 2. At a session of the Academia Nacional de Medicine, Caracas later the same year. The two presentations were not identical and the current contribution is different, although very much related to both. ☆☆ Presented in part at the History of Dermatology Society Seminar, March 15, 2012, San Diego, CA, at a session of the Academia Nacional de Medicina, Caracas, Venezuela, xxx, 2012. ⁎ Corresponding author. Fax: 58 212 7308861. E-mail address: [email protected]. 0738-081X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clindermatol.2013.08.021
Whatever happened? Who intervened in important events? What is the legacy that was left? These are the basic questions posed by the history of medicine and of dermatology. The study of both documents and archives and of oral tradition allows us to preserve pertinent knowledge and to answer the questions just mentioned above. In this way, we can understand how medicine and its specialties were formed and their respective definitions, rules, and regulations promulgated. There is much more. How does medicine or dermatology relate with the national or international historical phenomena? How do world currents of opinion, plus geographic and economic factors, interact? How is it that selected individuals may seem to lead history at certain times? How does history lead individuals most of the time? Modern science has discovered new revolutionary techniques. How can these be applied to medical historical knowledge? This contribution illustrates some examples of what has been outlined in the paragraphs above.
History, dermatology, and medicine: Another outlook
The other vision New technology New technology has revolutionized and will continue to revolutionize historical analysis. A small disc may include all human populations that have existed from 3200 BCE to 2009 CE as shown in a contest of photographic images shown in Science in 2011.1 In the figure, even losses by war and epidemics are shown in blank spaces. Academic life consists in great part of the analysis and assimilation of knowledge through texts. This effort can nowadays advance exponentially by means of quantitative analysis of digitalized texts. This permits a deep and, at the same time, extensive view of the fundamentals of scientific, medical, or literary culture. It also allows the possibility of integrating knowledge in a nontheological Summa. The term that has been used is that of “culturomics.” It is most tellingly told in reference2 that covers this subject and comes from a journal, such as Science.
The rule of just laws Organized societies need effort, goodwill, and a just or at least acceptable, legal structure to maintain themselves. When this structure is broken, societies dissolve themselves, and results are evident and showy. Spengler cites the writings of an Egyptian prophet who tells what happened in his country when the Middle Empire fell in the 17th century BCE:3 The High Officials have been deposed, the country has been deprived of its monarchy by a few fools and the counselors of the old state court to the upstarts. Administration has ceased and documents have been destroyed. All social distinctions have been suppressed and the courts of law have fallen in the hands of the mobs.
The quote continues afterwards: Theft and Murder reign, cities are deserted, public buildings are being burnt. Harvests dwindle … no one thinks about cleanliness …
I do not think that I am wrong when I suppose that many of the readers, including myself, do not find this description to be strange or distant. There is no need to go back that far in time. What happened in Hitler’s Germany was not very different from what was told by the Egyptian prophet. How did this influence dermatology?4 In less than a decade (1932-1940), the number of dermatologists in Germany dropped precipitously due to death (including suicide and prison)
171 and migration. Figures would even be more striking, if the period analyzed would be prolonged to 1945. Dermatologists and physicians of all kinds left Germany and spread throughout the four corners of the world. 4 German medicine in general and dermatology in particular was at the top up to the 1920s. Their full recovery to their former place has not happened yet, nearly 70 years after the fall of Hitler; yet, the disgrace of some is the benefit of others. United States´ medicine, as well as Brazilian, Turkish, South African, British, Israeli, and even Venezuelan medicine, benefited from the seeds dispersed by the rotting German fruit. The best parallel of the mixture of the tragic and irreparable with what becomes fertilizing is perhaps the fall of Constantinople. The latter lead to the beginnings of the Renaissance and the scientific explosion in Italy, from Leonardo to Vesalius.
The Janus face of migration We have already noted that migration, vis á vis tyranny, war, poverty (even newly emerged poverty), and social decomposition, is painful but might be saving and fertilizing. The examples shown indicate a flow from old civilizations to new or unrefined societies. There is also a migration of the reverse sign. This migration goes from new or underdeveloped countries to cultured and prosperous societies. In the case of medicine and other sciences, it is common to speak of “brain drain.” There have been efforts to block that flow by means of rather absurd notions of “justice” that do not resist an objective analysis; still, the brain drain is or might be a real problem and has valid solutions. The latter do not include the building of barriers and the prohibition of exit or entrance of persons that only wish to develop themselves and to contribute to their well-being, as well as that of societies that are able to use them appropriately. The solution lies in providing at the birthplace of physicians and scientists conditions such that would allow them to carry out respectable and beneficial tasks. This should be done by societies and mostly governments. Such an initiative took place in Mali as shown in reference. 5 I do not know whether recent turmoil in Mali has damaged this initiative. Venezuela, created in the early 1960s and 1970s, two institutions that served the purpose outlined above: the Venezuelan Institute of Scientific Investigation (IVIC) and the National Council of Scientific and Technological Research (CONICIT). The former is still working today, while the latter has been dismantled in the 21st century. About two years ago, I published a paper called “On Potted Palms.”6 Two potted royal palms, languishing in the narrow confines of their respective pots, were able to grow when transplanted to appropriate soil; thus, physicians and scientists need an appropriate soil to grow and reach the size of which they are capable. If they are confined to narrow places that oppress and limit them as
172 the ancient reducing shoes of Chinese ladies, they shrink and deform.
The roles of open economy and culture Scientific evolution of countries depends on conditions of their culture and their economy. A comparison between three countries, Germany, Turkey, and Egypt, was published in Science,7 but why these three countries? Partially, due to the great interest that there has been in the evolution of Egypt after the so-called Arab Spring; however, mostly, because neither Egypt nor Germany or Turkey are common countries. In addition, there are features in their respective histories that justify comparisons. Egypt is the country that has been at the forefront of advances in culture, science, and technology for the longest time in history. Six thousand years ago, it already had an organized civilization. Thirty-five hundred years ago, it recovered from the disaster described at the beginning of this contribution and played a leading role in the struggle of midEastern empires. Twenty-two hundred years ago, it had the best medical school of the world, that at Alexandria. A thousand years ago, Egypt had the largest hospital in the world. Turkey was the most powerful world empire up to 300 years ago and was a considerable world power until the end of World War I. Its shipping industry and its maps were at one time unsurpassed. Germany was restructured 143 years ago, and in 20 years, it was at the head of the world, at least in science, medicine, and social security. After the catastrophe of two world wars and under United States protection, Germany recovered a great deal of its scientific and technological capacities. In two decades, it also rehabilitated its unfortunate half that had been under the communist yoke for 50 years. Germany has shown clearly that science and knowledge progress under the aegis of freedom and order. Turkey, after the downfall of 1918, accepted under Kemal Atatürk a modicum of freedom and a lay system. This plus the influence of German migrants (many Jewish) and of the United States has allowed Turkey to reach an intermediate status both economically and in scientific production. The same has not happened to Egypt until now. The publication in Science 7 was optimistic in that a new day was approaching for Egyptian science. Events since then underline again the overwhelming importance of politics in the development and wellbeing of scientific endeavors. In June 2011, Egyptian Nobel Laureate Ahmed Zewail spoke at or near Tahrir Square about his plans for a “Cairo Caltech.”7 I am sure that current speeches at Tahrir Square are regrettably not about institutes for science and technology. There is a need to address specifically the issue of simultaneously analyzing and understanding scientific, public health, and medical care and politics. This was done in reference to Brazil in the Lancet.8,9 Brazil is a country that
M. Goihman-Yahr has always had a future but has been desperately looking for a present. It may be that the latter is taking shape nowadays. In the papers cited, authors underlined the system of communicating vessels that exist between legal, political, medical, and scientific factors. Just as an example, in the period that had been characterized as “democratic instability,” (1945-1964) the macroeconomic and socioeconomic context concerned import substitution, ie, urbanization, and penetration by foreign capital. The political character was that of liberal populist governments. The health system featured the establishment of the First Ministry of Health (1953), with emergence of a private business sector in health and laws that unified social security rights of urban workers (1960). Key health challenges were the emergence of “modern diseases” (eg, chronic degenerative diseases, as well as labor and traffic accidents). Very recent developments in democracy since 1988 have been in an upward line. A note of caution that I, as a Venezuelan, would like to make is that upward lines are not always persistent. In Venezuela, advances made in Brazil in the last two decades or so, were made back in the 1940s to the 1970s. In Venezuela, the upward line started to change its slope in the early 1980s and it went into a steep decline starting in or around the year 2000.
The take-home message The end message of this contribution is well illustrated in the front page of an issue of Science.10 The spacecraft Rosetta visited, photographed, and analyzed asteroid 21 Lutetia, a remnant planetesimal from the early solar system. Besides the significance of the names involved, this also shows the need that we, dermatologists immersed most of the time in details (using the microscope and the dermatoscope), should also look outwards using the telescope and the space-probe to understand, within the possible, the image of the whole.
References 1. Crnokrak P. Everyone ever in the world. Visualization Challenge (Honorable Mention). Science. 2011;331:851. 2. Michel JB, Shen YK, Presser Aiden A, et al. Quantitative analysis of culture using millions of digitized books. Science. 2011;331: 176-182. 3. Spengler O. The Decline of the West (translated into Spanish) EspasaCalpe, Madrid, 1958, Volume II p 499. (The citation was translated into English for this article by M Goihman.). 4. Scholz A. The decline of dermatology during national socialism. In: Scholz A., Holubar K, Burg G., et al. eds. History of German Language Dermatology. Germany: Wiley-Blackwell, 2009. pp 96-138 (parallel texts in German and English). 5. Taylor DA. News Focus Profile: Ogobara Doumbo. Mali researcher shows how to reverse brain drain. Science. 2011;332:1498-1499.
History, dermatology, and medicine: Another outlook 6. Goihman-Yahr M. On potted palms. Dermatol Online J. 2011; 17(6):14. 7. Lawler A. News Focus. A new day for Egyptian science? Science. 2011l333:278-284. 8. Paim j, Travassos C, Almeida C, et al. Health in Brazil 1.—The Brazilian health system: History, advances and challenges. Lancet. 2011;377:1778-1797.
173 9. Victora CG, Barreto ML, Leal M, do C, et al. Health in Brazil 6.— Health conditions and health-policy innovations in Brazil: The way forward. Lancet. 2011;377:2042-2053. 10. Sierks H, Lamy P, Barbieri C, et al. Images of Asteroid 21, Lutetia: A remnant planetesimal from the early solar system. Science. 2011;334: 487-490. (The figure alluded to appeared on the front page the corresponding issue [October 28, 2011] of Science.)
