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Philosophy of Science: What does Kuhn’s theory of scientific revolutions say about the history of medicine?

Before I address the question, I will address Jan Chan’s answer: “Kuhn’s philosophy of how science works has largely been discredited within the scientific community.” That’s an interesting point of view, and I’d be interested in any evidence you might be basing that assertion on.

Kuhn’s work has not been discredited by the scientific community. It is controversial because many scientists resist the idea their vaunted “science” isn’t an objective means of arriving at “the truth.” Science is highly subjective and influenced by unconscious beliefs and assumptions about the nature of reality, which are completely outside the awareness of the observer/scientist.

Observation isn’t objective; it is subjective and theory laden. And, observation cannot occur without a paradigm. Without a paradigm, there is no experiencer, no self, there is just a sea of undifferentiated stimuli. Helen Keller described the experience of the shift from no language/no paradigm/no self to a self, experiencing, which occurred due to her acquisition of language, which occurred precipitously during Annie Sullivan’s repeated signing of “water” onto Keller’s hand while holding it under running water… when Keller got language, she got you, I, and a whole world sprang into being… the direct consequence of a paradigm (constructed of language) springing into being.

Further, what is passing for science today isn’t science, it is scientific materialism, which is based on certain assumptions which are taken for granted. The fundamental tenets of scientific materialism are:

1. Only the physical world is real. Anything outside the physical world is not real.

2. Only the material influences the material world, i.e., nothing outside the material world influences the material world

3. Reductionism – We are only the sum of our parts, not more than the sum of our parts, i.e., if you have an emotional or spiritual experience it is “nothing but the result of chemical activity in the brain.”

Put another way, “If you can’t see it in a laboratory, it doesn’t exist.”

I assume many, or most readers will think, “Yes. That’s correct. Those aren’t assumptions. Anyone who believes otherwise is foolish.”

The history of medicine is the history of one paradigm shift after another.

Max Planck once said, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.”

“All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.”

– Arthur Schopenhauer

“The four stages of acceptance:

  1. This is worthless nonsense.
  2. This is an interesting, but perverse, point of view.
  3. This is true, but quite unimportant.
  4. I always said so.”

– J.B.S. Haldane

“When a thing is new, people say:

  • ‘It is not true.’
  • Later, when its truth becomes obvious, they say: ‘It is not important.’
  • Finally, when its importance cannot be denied, they say: ‘Anyway, it is not new.’”

– William James

The observations made by these men are self-evident and point to the phenomenon pervasive in science, but poorly understood until the work of Thomas Kuhn.

Let’s review a fascinating story from the history of medicine, while recalling, “If you don’t remember it, you’ll repeat it!”

Crackpots in Medicine

This is the story of the life and work of Dr. Ignaz Semmelweis, Austrian/Hungarian obstetrician, born in 1818 and dying a horrible death on August 13, 1865, at the age of 47, two weeks after he was tricked into entering an asylum close to Vienna General Hospital where Dr. Semmelweis used to be the head of obstetrics. Semmelweis, upon figuring out what was going on, tried to leave, was detained, became aggressive, was beaten and died two weeks later of his injuries.

This story demonstrates the power and applicability of Thomas Kuhn’s work on the scientific revolutions that occur, though very slowly, in medicine.

Who is this beaten-to-death-in-an-insane-asylum, Ignaz Semmelweis, M.D.? There are two answers to that question: Then, he was the vocal crackpot, coaxed into an asylum as he was crazy and needed what they had to offer; today, he is the Savior of Mothers in Austria, and his face is on Austrian postage stamps. Why?

Here is a description of childbed fever by Howard Markell, MD, director of the Center for the History of Medicine, who had this to say in his May 2015 PBS health blog on Dr. Ignaz Semmelweis, “In the mid-19th century, about five women in 1,000 died in deliveries performed by midwives or at home. Yet when doctors working in the best maternity hospitals in Europe and America performed deliveries, the maternal death rate was often 10 to 20 times greater. The cause was, invariably, childbed fever. And a miserable end it was: raging fevers, putrid pus emanating from the birth canal, painful abscesses in the abdomen and chest, and an irreversible descent into an absolute hell of sepsis and death — all within 24 hours of the baby’s birth.”[1]

In the 1840’s, Dr. Semmelweis was assigned as the head of obstetrics at Vienna General Hospital. In their outpatient OB department there were two clinics: the First Obstetrical Clinic and the Second Obstetrical Clinic, and they treated patients on alternating days. In the First Obstetrical Clinic medical students were trained; in the Second Obstetrical Clinic midwifery students trained. In the First Obstetrical Clinic typically between 10 to 35% of young mothers, after delivery, died the horrible death described by Dr. Markell. In the Second Obstetrical Clinic, where midwifery students trained, less than 2% died of childbed fever. This horrific and abominable situation was just accepted, as every good doctor knew disease was caused by an imbalance of the basic four humors of the body, which was not a theory, or the current theory, or the current working theory, or a hypothesis, it was “the way it is.” They had cutting edge treatments back then, too, just like during every period of the history of medicine, they just were very different than the cutting edge treatments of today and the cutting edge treatments of other eras of medicine, each of which operated inside different paradigms.

Semmelweis did not accept the high death rate in the First Obstetrical Clinic, as it sickened him, and he was afflicted with the powers of critical thinking, leaving him somehow able to make observations unfettered by “the way it is”; and he made three observations over time, figuring the whole tragic thing out. What were those three observations?

First observation: Women who delivered before arriving at the hospital rarely died of childbed fever. These street births happened a lot because the fact the death rate was much higher in the First Obstetrical Clinic was known outside the hospital. So, if you went into labor on a day when the First Obstetrical Clinic was taking patients, you desperately tried to have a street birth; if you succeeded, you didn’t die. If you could just get your baby out before they got you through the doorway of the First Obstetrical Clinic, you lived. Seems like a big clue to us today; but notice, it was also a big clue to the lay public way back then, but not to the physicians of the day. Lay public then, lay public now, and traditional medicine now: the street birth thing is a big clue. Traditional medicine then: clueless in the face of that which was right before their eyes. Blind. They didn’t question the paradigm, because to them there was no paradigm; there was just “the truth.” (This reminds me of the riddle: When is a superstition not a superstition? Answer: When it’s a superstition.)

The low death rate of women managing the good fortune of a street birth was an anomaly.[2] “We don’t know how giving birth in the street versus in the fine First Obstetrical Clinic affects the basic four humors of the body. We admit we can’t explain it. It is puzzling. We do know that we don’t believe in crackpot theories about invisible particles. Don’t you worry about that. Now, come on in here, let’s take a look and get that baby out.”

Second observation: Doctors and medical students did autopsies in the morning on women who died of childbed fever, for teaching purposes, before going to the First Clinic to deliver babies. The midwifery students were not permitted to participate in autopsies.

That should be enough clues, but it wasn’t. Semmelweis logically concluded the autopsies were pivotal and began to hypothesize the existence of invisible “cadaverous particles”, but he wasn’t certain enough to begin experiments on the basis of that hypothesis. Perhaps Semmelweis, educated in the traditional medical paradigm, thought, “What do I know?” Dr. Semmelweis required a third clue, a tragic and ironic one.

Third observation: One morning, his close friend and colleague, Dr. Jakob Kolletschka, Head of the Department of Pathological Anatomy, was performing a teaching autopsy on a woman who had died of childbed fever for the benefit of a young medical student. Perhaps the young medical student was nervous or sleepy or bored or had ADD, I can only offer conjecture on that. What is not conjecture is the medical student cut Dr. Kolletschka’s finger with a scalpel.

Guess what happens to Dr. Kolletschka? High fever, streaks up the arm of the pricked finger, develops all they signs of childbed fever, meningitis, peritonitis, pericarditis, and he died the same horrible death as those innocent young mothers on their watch. Dr. Kolletschka died of childbed fever after receiving an open wound inside the bloody corpse of a victim of childbed fever.

Kolletschka’s death due to childbed fever deeply disturbed Semmelweis, and he began acting on his hunch/hypothesis that childbed fever was caused by invisible particles that were carried from the dead to the living by doctors and medical students who were performing autopsies before clinic hours where they delivered babies.

Dr. Semmelweis’ experiments involved hand washing with various cleansing agents after morning autopsies, soap and water failed to remove these unseen particles. When he stumbles upon chlorinated lime solution, which contains calcium hypochlorite, the active ingredient of household chlorine bleach, the death rate dropped dramatically, some months to zero.

Dr. Semmelweis was understandably very vocal in sharing this dramatic (rapid, safe, inexpensive, and highly effective) breakthrough with his colleagues. The medical community greeted Dr. Semmelweis’ discovery and breakthrough cure of childbed fever with “skepticism” and ridicule. Those two words are from Wikipedia. I take exception to the use of these words. Ridicule, yes. Skepticism, no.

Skepticism in a scientific community doesn’t mean saying, “That’s impossible,” or “That’s B.S.,” or even “I doubt it.” Skepticism in a scientific community means neither accepting nor refuting a theory without investigation. Dr. Semmelweis’ contemporaries did not respond with, “Dr. Semmelweis, your proposed mechanism of action for the death of women afflicted with childbed fever is ludicrous; however, even though we don’t understand how it works (meaning how hand washing with chlorinated lime solution affects the basic four humors of the body), we do see the distinct correlation between hand washing with chlorinated lime solution after morning autopsies and patients not dying like flies.” If they did refer to the high death rate in their morbidity and mortality reviews, they would have been unlikely to use the term “dying like flies”; they would much more likely have said, “dying,” “expiring,” or “passing away.” I believe the first term is more appropriate, as it also communicates something more than just the matter-of-factness of the high mortality rate. But, I admit it’s unlikely Semmelweis’ contemporaries would have used “dying like flies” to refer to the fruits of their labor and for the high mortality of their patients, for obvious reasons.

For more abomination, here is a quote from a famous Semmelweis contemporary, Dr. Charles Meigs. He’s famous, in my opinion, for the wrong reason. He’s famous enough that a medical student, uninterested in pursuing obstetrics as my specialty, nevertheless remembers Meigs Syndrome. It is not an important syndrome, nor should it be, in retrospect, as Meigs is responsible for an increase in the mass homicide of young women who should have been experiencing one of the happiest times of their lives. Why? Dr. Meigs, the expert, weighed in on the crackpot Semmelweis’ theory and went on record saying, “Doctors are gentlemen, and gentlemen’s hands are clean.” Thank you, Dr. Meigs.

The U.S. healthcare system appears quite scientific. Is it? This is a rhetorical question. Modern medicine is based on tradition, not science; as physicians, we are apprenticed into the tradition of diagnosing and treating illness; and, tradition and science are antithetical. Tradition says, “This is how it is,” and science asks, “Is it true?” If you ask, “Is it true?” in a traditional setting, it doesn’t go well.

John E. Sarno, MD, a retired physiatrist at NYUMC and professor of rehabilitation medicine at NYU School of Medicine, cured 90% of his chronic pain patients for decades, and he was ignored. That’s not science. Even though he is a best selling author; has been on national television many times; and has cured many famous people, such as Howard Stern and John Stossel of ABC News 20/20, he is virtually unknown. This is because of a paradigm. The paradigm is, “Back pain is caused by injury, damage, and structural problems of the spine, like herniated discs,” even though that is not possible. Herniated discs can’t even contribute to back pain because if they did, they would be seen more often in people with back pain than without. CT’s and MRI’s of the spine show roughly two thirds of adults have at least one bulging or herniated disc in the spine, and those herniated discs are not seen any more often in people with back pain than without. Game over for that theory (assuming critical thinking is being used… which, it turns out, is a huge assumption in modern medicine.)

Further, back pain was uncommon in the U.S. sixty years ago. Belly pain caused by peptic ulcer disease was common; but, about sixty years ago, belly pain started declining and an explosive epidemic of chronic regional musculoskeletal pain began, and it grew 14 times faster than the population for decades. Did something terrible happen to the American back?

Further, traditional medical treatments for chronic back pain are ineffective, which is suggestive the diagnosis is incorrect.

Sarno’s treatment for back pain produces a cure in 90% of his patients, which is suggestive his diagnosis is correct. In a scientific community wouldn’t there be a flurry of investigation to rule in or rule out this highly effective treatment? Dr. Sarno doesn’t get flak from the medical community and that isn’t because it isn’t known about… Dr. Sarno is high profile, yet ignored, as seen on ABC News 20/20 and other national television shows, yet his work is ignored. That ignorance of Sarno and his work, coined “The Semmelweis Reflex” for the automatic rejection, out of hand, without any investigation whatsoever, is not science and IS THE PRODUCT OF A PARADIGM.

It’s actually two paradigms:

1. Matter and energy are all there is, and therefore, if you can’t see it in a lab, it doesn’t exist (obviously not true, just from this example of back pain);

2. Traditional medicine is based on: tradition (the antithesis of science),

U.S. healthcare is in a state of crisis, which is an expression of Kuhn’s model of how science progresses. Human beings are not machines that break, and no one is going to intervene on the patient’s behalf and restore them to health. There’s no cure coming. If a scientific breakthrough occurs tomorrow, such as a stem cell smoothie, and everyone with a chronic illness were given the smoothie cure, which led to the development of a perfectly healthy, perfectly functioning body over the next few days; every one of them would be sick again within a year.

Curious what correlates with chronic back pain? (Remember, it isn’t imaging studies of the spine…) Perfectionism and codependency. The high correlation would be noted by an individual who possessed and utilized the skill set called, “critical thinking.” However, since the paradigm determining the perception of the individual possessed by the paradigm is, “If you can’t see it in a lab it doesn’t exist,” the highly effective treatment of Dr. Sarno is rejected outright. And it is the paradigm that does the rejecting, not the person possessed by the paradigm.

The brilliant work of Thomas Kuhn on the structure of scientific revolutions (collective level) interestingly parallels the structure of cognitive revolutions on the individual level, as elucidated by Jean Piaget, playfully recreated here:

The power went out briefly at my Dad’s house recently, and he reminded me of a time when he had to find a youngster, like me, to reset all of the blinking clocks in the house. Sometimes those clocks flashed 12:00 for a long time. It’s not so easy to move from the current paradigm (“the way things are”) to a new one. A friend of mine, Kristina, can relate. She came late to the smart phone party. Her teenage son finds it quite funny when she punches the “keys” on it harder when her smartiephone isn’t cooperating. A clashing of paradigms.

Piaget’s learning theory applies here. How do humans adapt to new stuff? His theory sees intellectual growth as a process of adaptation or adjustment to the world; and, it isn’t a linear process. It occurs in discontinuous leaps or breakthroughs. Three phases can be distinguished: assimilation, accommodation, and equilibration. (In Kuhn’s work the cycle is: normal science, anomalies, crisis, revolution, new paradigm, normal science in the new paradigm; more stages, same cycle, no difference… whether you have three steps or six steps from the basement to the first floor isn’t material.)

Assimilation is using the existing schema, paradigm, or point-of-view to deal with a new object, situation or information.

Accommodation occurs when the current point-of-view doesn’t handle the new object, situation or information and needs to be changed to deal with it.

According to my understanding of Piaget, equilibration occurs repeatedly in development in a series of discontinuous leaps higher. In relation to the paradigm being left behind, the new paradigm is not more, better, or different than the old paradigm. The new paradigm doesn’t negate the old paradigm; it transcends and includes the old paradigm. There are long periods where a child’s schema (paradigm) can deal with most new information by assimilation. And, an uncomfortable stage of disequilibrium begins building, as the child’s current paradigm can no longer deal with the new information. This discomfort fuels a drive to master the new information and restore equilibrium. Thus, accommodation is a breakthrough into a new paradigm or worldview that does handle the new information. The new information is acquired, and the worldview shifts in a dramatic breakthrough into a higher level of cognitive or intellectual development. Then, the process of assimilation begins once again inside the new paradigm until the breakdown/breakthrough occurs in the child’s schema; and, the child’s cognitive tectonic plates shift abruptly under the continuous strain of unworkability and discomfort of the now aging previous breakthrough.

As adults, this process isn’t guaranteed to continue. Sometimes we get stuck, and we become assimilators. As assimilators, we make new information fit what we already “know.” This process involves rejecting stuff that doesn’t fit our view of “the way things are.” An assimilator is not referred to as open-minded and no assimilators boarded the Niña, the Pinta, or the Santa Maria willingly. The assimilator would have said, “No, thanks, Chris, you have a nice trip. We’ll take care of your wife and kids.” No new world for the assimilators.

In accommodation, what’s “known” is altered as new and contradictory information presents itself. Accommodators would be referred to as open-minded (or gullible if an assimilator is doing the talking)… but, guess what? The New World is possible for the accommodators. A New World isn’t guaranteed for accommodators; and, no New World is a guarantee for the assimilator.

Modern medicine is an assimilator. As a whole, modern medicine is not based on science. As aptly pointed out by Andrew Malleson, modern medicine is based on tradition. As physicians, we are apprenticed into the tradition of diagnosing and treating diseases. Unfortunately, tradition and science are antithetical. Tradition says, “This is the way it is.” Science asks, “Is it true?” As the French philosopher, Michel Foucault, pointed out, there is, in medicine, a dominant mode of discourse; that which is outside the prevailing view is marginalized, repressed or ignored. The United States has the most expensive, ineffective and deadly healthcare system in the world, but it isn’t because we know what we are doing; you can’t tell us that. Nobody knows more than doctors.

There is nothing but paradigm. No paradigm, no self, no perception. (Please read Helen Keller’s account of getting language and being/subjectivity. It’s fascinating and relevant.)

I won’t answer the second part of the question about Popper’s “falsifiability”. I find Popper’s work an attempt to elevate science to a status higher than it deserves, and no scientist is going to practice falsifiability; he or she will consciously or unconsciously practice the opposite. Between Popper and Kuhn, there’s no contest. Kuhn’s work is highly insightful and relevant. Popper’s work is theoretical and irrelevant and scientists don’t attempt to falsify their work out of their love of “the truth.”

Progress in science is something like climbing a mountain. Only most mountaineers don’t set up a new base camp every ten feet, then leap out and attack anyone who tries to climb past them. – Unknown

Sufficiently anomalous discoveries are indistinguishable from pseudoscience. – Unknown

The banner of “open-mindedness” attracts charlatans and gullible fools, just as the banner of “skepticism” attracts bigots and the narrow-minded. This is no reason for the skeptical scientist to see open-mindedness as foolish gullibility, or for the maverick scientist to assume that all skeptics are narrow-minded bigots. – Unknown

And, I say, if you say, “It’s impossible,” you’re no longer practicing science and you are no longer a scientist.

How can you possibly know what’s impossible? – Frank S. Murphy, DO

Many things are not worth bothering with; however, Dr. Sarno’s work can be ignored or discounted, but it can not be refuted.

If you say, “It’s impossible,” you are not practicing critical thinking, you are not being scientific, and the rejection/refutation without critical thinking and scientific merit is being done BY THE PARADIGM THAT HAS YOU. You’re not thinking; you’re having thoughts, and those thoughts are generated by the paradigm one is consciously or unconsciously inside of. The one that says, “What paradigm?” or, “BS!” or, “Quack!” or, “Psuedoscience!” or, “Charlatan!” or whatever else the mind and its paradigms are spitting out.

That’s my answer, and I’m sticking to it until I don’t anymore. It’s not the truth; it’s a theory generated by the paradigm I am (the paradigm the being over here is currently identified with or as.) That may sound funny, or like bad English, or a typo… and it isn’t… it’s what ontologically precise languaging sounds like. It’s not easy to talk about being, and the mind generally isn’t interested in being; it’s interested in doing and having. Human doing? Human having? Human being?

Question answered. So you know I know: This is an answer, not the answer. It may all be wrong.

William James, father of American psychology, tells of meeting an old lady who told him the Earth rested on the back of a huge turtle.

“But, my dear lady”, Professor James asked, as politely as possible, “what holds up the turtle?”

“Ah”, she said, “that’s easy. He is standing on the back of another turtle.”

“Oh, I see”, said Professor James, still being polite. “But would you be so good as to tell me what holds up the second turtle?”

“It’s no use, Professor”, said the old lady, realizing he was trying to lead her into a logical trap. “It’s all turtles, turtles, turtles, all the way down!”[3]

There you go…

Paradigms… It’s all paradigms, paradigms, paradigms, all the way down.

Good Night. Thanks for listening.

[1] Markel, Howard. (2017) In 1850, Ignaz Semmelweis saved lives with three words: wash your hands | NewsHour. Retrieved May 31, 2017, from In 1850, Ignaz Semmelweis saved lives with three words: wash your hands

[2] This term was brought into more common usage by Thomas Kuhn, philosopher and historian of science and author of The Structure of Scientific Revolutions, which shook up the scientific, but not medical, community, starting with its publication in 1962. It has since sold over 1,000,000 copies in the United States.

[3] Wilson, R.A. (1983, 1997) Prometheus Rising. Phoenix, AZ: New Falcon Publishers, 1983.