IJE Advance Access originally published online on May 11, 2009
International Journal of Epidemiology 2009 38(3):646-649; doi:10.1093/ije/dyp185
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Commentary: From history of medicine to a general history of ‘working knowledges’
Centre for the History of Science, Technology and Medicine, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
E-mail: john.pickstone@manchester.ac.uk
Accepted 9 March 2009
For teachers of history of medicine, few papers have proved more useful than Jewson's essay on the Disappearance of the Sick Man1 and its companion piece on Eighteenth-Century Patronage.2
The Disappearance has provided structure for many survey courses in history of medicine, at least for Britain. In a convenient form, if not the easiest of language, it underlined the crucial role of the Paris hospitals after the Revolution, thus linking with the work of Michel Foucault on the ‘Birth of the Clinic’.3 Through Althusser and through Foucault, it linked with the French tradition in history and philosophy of science, but also with the work of Owsei Temkin, Erwin Ackerknecht and the other European émigrés who in the USA had established history of medicine as a sophisticated aspect of the history of ideas (and the cultured sibling of post-war American history of science).
Unlike Foucault, however, Jewson set out the social as well as the cognitive aspects of eighteenth-century medicine, and he added a section on medicine in laboratories, linking his story to the present. Here was a three-step history—of private patronage, of state hospitals and of laboratories—where the focus shifted from Britain to France and then to Germany.
But there was more to Jewson that the three-stage frame for modern medicine. For all three steps, he related knowledge production to patterns of professional work and power—from the eighteenth-century doctors’ deference towards the ‘philosophies’ of their patrons, to early nineteenth-century professional competition over pathological novelties in Paris hospitals and museums, to the later University world of biomedical research projects. Jewson's presentation of medical knowledge, practice and politics as mutually constitutive chimed with developing approaches in the history of science and sociology of knowledge more generally, though it was rarely referred to by historians of ‘science’.
As noted, Jewson's frame drew on American studies as well as French. His discussion of neo-classical England echoed the work of Edelstein on classical Graeco–Roman medicine,4 whilst the interpretation of Paris medicine could use Temkin's articles on surgical views of the body as foundational for the new Paris physicians.5 Erwin Ackerknecht, versed in anthropology as well as medicine and history, had independently written a comprehensive account of Paris medicine, though it was too much like a telephone directory to appeal beyond historical specialists.6 In his general survey of history of medicine, however, Ackerknecht also experimented with four ‘types’ of medicine: medicine of the book, bedside medicine, hospital medicine and laboratory medicine.7,8 It was through Jewson that the last three types became influential.
It would be good to know more about the immediate context of Jewson's work. The Sociology department at Leicester, uncommonly for Britain, then included the Germanic tradition of historical sociology, which had helped form Edelstein, Temkin and Ackerknecht. Norbert Elias, who had studied medicine and philosophy in Germany, worked with Mannheim and been a friend of Temkin, was at Leicester with Ilya Neustadt from 1954 to 1962 (and on a part-time basis to the 1970s). Not until after his retirement did Elias achieve a wide following, but at Leicester he was a founder of sociology of sport. This was the field to which Jewson turned.9 Through the work of Ivan Waddington (who also turned to sport) and the medical historian Sidney Holloway, Leicester became noted for a rather different type of historical sociology of medicine, one focused on professionalization rather than cosmologies.
Jewson's systematic and symmetrical accounts have also proved useful at the level of historical method, for exploring the function and justification of models. To be sure, it was easy to question the three Jewson modes, especially when they were treated as a simple chronological series; but in my view, most of the questioning has proved constructive. Explorations of eighteenth-century medicine showed that the majority of practitioners were solid members of the middling classes, like the majority of their remunerative patients,10 not aristocrats of limitless means. Thus full-blown bedside medicine routines, with their detailed attention to the patron's biography and elaborate prescriptions of modes of life, must have been statistically uncommon. But these routines may, nonetheless, have been the professional ideal—with other forms of practice regarded as pragmatic abbreviations. We know, for example, that ‘family medicine’ was important to many twentieth-century general practitioners, even though they spent most of their time on other kinds of practice. We know too that in classical Greece, medicine for slaves, sometimes practiced by doctors who were themselves slaves, was seen as abbreviated from practices of the ‘bedside’ type.4
A similar set of useful criticisms surround the claim that the Paris hospitals invented a new form of medicine. Various scholars have shown that elements of the new model could be found earlier, for example, among British surgeons or in military hospitals.11 Such facts are sometimes regarded as undermining the model; but this is simplistic. If we see the new medicine as a product of social configurations, then the earlier presence and interactions of some of its cognitive and social elements supports a more subtle version of the argument. So do the subsequent limitations of Paris medicine evident in countries such as England, where the teaching hospitals depended on lay governors and subscribers who were nervous of public opinion and thus limited the ‘objectification’ of patients through mass post-mortems. In the UK and elsewhere, where doctors continued to depend on choosy patients, some aspects of bedside medicine would persist, albeit in combination with any useful findings from hospital medicine.
Thus the historical analysis may profitably shift from a series-model of successive types of medicine to a model of co-existence and inter-penetration of types; from replacements to more complex displacements, where novel forms co-exist with the old in contested cumulations. Though that way of using the model is licensed by Jewson's text, it has not been the usual presentation. For me, however, this revision is the key to a more successful modelling of medical practices and cosmologies, and one which can also be extended to other areas of science and technology. In the rest of this review, I want to outline this revision and its extension, beginning with two suggested improvements on Jewson's model of medicine.
The first is to deconstruct slightly the notion of bedside medicine, in line with a commonplace of medical sociology: that notions of disease are cultural as well as natural, with no clear line between them. ‘Ideals of life’ were among the cultural aspects of bedside medicine portrayed by Jewson. They connected with the social and moral assumptions of that class of patient, but they could also be linked with attention to characteristic patterns of symptoms that were regarded as ‘natural’ and universal. While it is often useful to take both aspects of bedside medicine together, it is sometimes useful to distinguish the cultural system from the natural history, albeit allowing that ‘natural readings’ were and are ‘cultural’ in their framing. Here, we can further suggest that ‘biographical’ may be a better term than ‘bedside’—partly because other kinds of medicine can be practised at bedsides, and ‘bedside medicine’ could be done by correspondence: partly in the belief that ‘projects’ rather than ‘sites’ afford the stronger primary basis for the analysis of science, technology and medicine (STM) more generally.12,13
My second suggestion, about ‘hospital’ and ‘laboratory’ medicine, likewise involves renaming in terms of projects rather than places; but it also involves the redrawing of a key boundary. I see hospital medicine as one aspect of a project of medical ‘analysis’ that was enormously elaborated from c.1800 through our present. It initial agents sought to characterize disease in terms of gross lesions of the body's tissues, in a new universalist pathology where the individuality of the patient as person had little or no place. But in this respect, gross pathological analysis seems little different from chemical analysis, or histology, or bacteriological tests—all of which were classed by Jewson as ‘laboratory’ medicine (along with physiological experimentation). Indeed, all the activities now characteristic of hospital laboratories, through to immunology and genetic analyses, seem essentially similar to each other (and to gross pathology) in their logical relations to clinical diagnosis or prognosis (if not, importantly, in their chronological relations to treatment). In contrast, the experimentation of Claude Bernard seems logically different in its ambition to use analysis to develop and demonstrate control. If analytical chemistry was the historical model for most medical analysis, experimentalist projects on animal models (and controlled clinical trials) may perhaps be compared with chemical synthesis as directly demonstrating power over nature.14–16
By such splittings and shiftings, we gain a model of medicine in terms of its constituent elemental projects, which may be said to ‘cumulate’ over time, so that they nest in complex and contested ways. All encounters between patients and diagnosticians are in part cultural interactions, where the roles of each party are understood in terms of symbolic actions. Additionally, for relatively trivial conditions in many cultures,17 and for many conditions in ‘western’ medicine, we find understandings of people and of diseases framed in terms of natural histories—of natural kinds, both of people and diseases. Within this naturalistic mode, one may also find attempts at substantive analysis, as in the many cultures where bodies, foods and environments have been described in terms of opposed qualities. The oppositions may be single pairings, such as ying and yang, or dual pairs (hot and cold, wet and dry); or the single scales of eighteenth-century medicine, which used the tensions of body fibres, the irritability of nerves.
Such schemes permeate our language still, and they were prominent in the biographical medicine that Jewson described. They may be predictive as well as explanatory, but characteristically there are few if any independent ways of assessing the relative quantities of the humours, for example. Such schemes seem to work by projecting ‘inwards’ the overt qualities of disease. In contrast, the new forms of analysis in ‘hospital medicine’ referred disease to specific organic lesions that could be assessed independently of the symptoms (though often, initially, only after the death of the patient). After Paris, as it were, diseases continued to have cultural meanings and natural courses, but they also had biological or chemical essences—located below the surface, in the body's elements (tissues, cells, nuclei, genes or whatever). A full description of a disease, in our medicine, is likely to involve components all these levels, as well as meanings and natural history.
From the late nineteenth century, however, it also became possible to model a few diseases in animals or in vitro. Through such model systems, experimentalists could explore means of control; and they later claimed successes—for example, the discovery of insulin in 1921. Thus too might genetic engineering produce designer drugs for controlled trials on ‘molecular diseases’.
These various re-modellings, beyond the normal readings of Jewson, seem to provide a fertile way of analysing complex medical interactions into elemental ‘working knowledges,’18 each with characteristic historical patterns. This is not a matter of taxonomic boxes into which any given case of medicine can be placed; which is indeed very limiting. Rather, we can treat these ‘types’ like the elements in analytical chemistry; so we can ask about the cultural, natural–historical, analytical and experimentalist components ‘within’ any given case of medicine. Thus the complex cases become the most suggestive, not the most awkward.
A substantial body of well-regarded work in recent medical sociology and anthropology remains content to marvel at the multiplication of perspectives to be found in and around any given disease or procedure.19 But one can surely be more ambitious, especially since indefinite complexity has a tendency to collapse back into a fuzzy unity. If we want a more robust way of handling variety, which neither collapses down nor limits the complexity of description, then analysis in terms of elemental ‘working knowledges’ seems promising.
In concluding this appreciation, I note that historical modelling by means of ‘projects’ or elemental working knowledges also seems productive across other aspects of science and technology. I have developed the argument in my book on ‘Ways of Knowing’, but can note here that the actors’ categories of knowledge before c.1800 can assist our argument about meanings, natural history and analysis: eighteenth-century savants commonly referred to (natural) philosophy, natural history and (mathematical) analysis. Then, from c.1800, the medical analysis pioneered in Paris was explicitly based on chemistry, and contemporary with the birth of many other substantive analytical disciplines, such as stratigraphy, political economy and statistical analysis.18 And then, from c.1870, the experimentalist work of Claude Bernard on physiology is closely associated Pasteur's variant of experimental medicine (and agricultural sciences), and with Berthelot's self-conscious promotion of synthesis as a new frontier in chemistry. By the end of the nineteenth century, all four modes were in force, in physical science as well as in medicine, and interacting in many ways.
Much historical work remains to be done, but there are good prospects for establishing a relatively simple model of STM that both respects the categories of historical actors and also facilitates our own analysis of the past; one that can highlight the co-constitution of cognitive, material and political aspects across the whole range of STM.
Perhaps it seems odd to suggest that the whole of STM might usefully be modelled and taught by a method developed in history of medicine, not least by Jewson. Yet medicine was long crucial to many sites of scientific education, and it is surely the form of normative technology best known to experts and to the public. The more we worry about the health of the globe, the more will studies of physical sciences and technologies become normative, like medicine. And the more we think about climate change or the global energy economy in terms of the interplays of cultural meanings, natural history, analysis and experimental technologies, the more will medicine and its history prove useful. Whether we are interested in the cultural meanings of new technologies, or even the place of analysis and controlled experimentation in social development, an ambitious and analytical history of medicine could be a major resource for thinking through the problems of ‘natural knowledge’ in the twenty-first century. In that respect, too, Jewson's work in the 1970s remains promising.
Conflict of interest: None declared.
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1 Jewson ND. The disappearance of the sick-man from medical cosmology, 1770–1870. Sociology (1976) 10:225–44. (Reprinted Int J Epidemiol 2009;38:622–33).[Abstract]
2 Jewson ND. Medical Knowledge and the patronage system in 18th century England. Sociology (1974) 3:369–85.
3 Foucault M. The Birth of the Clinic. (1973) London: Tavistock Publications.
4 Edelstein L. Ancient Medicine. Selected Papers of Ludwig Edelstein. (1967) Baltimore: Johns Hopkins University Press.
5 Temkin O. The Double Face of Janus. (1977) Baltimore: Johns Hopkins University Press.
6 Ackerknecht EH. Medicine at the Paris Hospital, 1794–1848. (1967) Baltimore: Johns Hopkins University Press.
7 Ackerknecht EH. A Short History of Medicine. (1982) Baltimore: John Hopkins University Press. 146.
8 Bynum W. The History of Medicine. A Very Short Introduction. (2008) Oxford: Oxford University Press.
9 Elias N. Reflections on a Life. (1994) Oxford: Polity Press.
10 Loudon I. Medical Care and the General Practitioner, 1750–1850. (1986) Oxford: Clarendon Press.
11 Fissell M. Patients, Power and the Poor in Eighteenth-century Bristol. (1991) Cambridge: Cambridge University Press.
12
Pickstone JV. Ways of knowing: towards a historical sociology of
science, technology and medicine. Brit J Hist Sci (1993) 26:433–58.[CrossRef]
13 Pickstone JV. The biographical and the analytical: towards a historical model of science and practice in modern medicine. In: Medicine and Change: Historical and Sociological Studies of Medical Innovation.—Loewy I, ed. (1993) Paris: Les Editions INSERM, John Libbey.
14 Pickstone JV. Ways of Knowing. In: A New History of Science, Technology and Medicine. (2000) Manchester: Manchester University Press.
15 Figlio K. The historiography of scientific medicine; an invitation to the human sciences. Comp Stud Sci Soc (1977) 19:262–86.
16 Hirst PQ. Durkheim, Bernard and Epistemology. (1975) London: Routledge Kegan Paul.
17 Horton R. Patterns of Thought in Africa and the West. (1997) Cambridge: Cambridge University Press.
18
Pickstone JV. Working knowledges before and after c. 1800: practices
and disciplines in the history of science, technology and medicine.
Isis (2007) 98:489–516.[CrossRef][Web of Science][Medline]
19 Mol A. The Body Multiple. Ontology in Medical Practice. (2003) Durham NC: Duke University Press.
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