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The Historiography of Scientific Medicine: An Invitation to the Human Sciences

Published online by Cambridge University Press:  03 June 2009

Karl Figlio
Karl Figlio
Affiliation:
University of Cambridge
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Extract

It is clear from the title that this paper has an historiographical emphasis, one which might seem naive to the professional historian, but one which is not at all so naive to the historian of science or medicine. For me, these disciplines should speak to the present; my aim is to direct our attention to the failure of the history of medicine in this respect, and to suggest possible linkages with the human sciences, whose energies are so directed. I do not mean that its subject matter must be drawn from contemporary events—sometimes the very foreignness of the past allows an encapsulation of a situation which gives a clearer view both of the constraints operative within it, and of the unities underlying apparent diversity. This clarity can then encourage a more perceptive reflexion back to the present.

Type
Theory and Practice of Medicine
Information
Comparative Studies in Society and History , Volume 19 , Issue 3 , July 1977 , pp. 262 - 286
Copyright
Copyright © Society for the Comparative Study of Society and History 1977

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References

The author gratefully acknowledges the help of Tom Anderson, Andrew Cunningham, Ludmilla Jordanova, Larry Miller, Mary Watts and Robert Young; this paper is revised from one delivered to the Department of History, University of Michigan, April 2, 1975.

1 There has been an explosion of literature in recent times, which both reflects and criticises these themes. R. Horton has brought an anthropological perspective to bear upon the comparison of western scientific thought with African “primitive beliefs,” “African Traditional Thought and Western Science,” in Young, M. F. (ed.), Knowledge and Control (London, 1971), pp. 205–67.Google Scholar The works of M. Douglas are especially important for their reflexion back on modern systems of thought. See Purity and Danger (London, 1966);Google ScholarNatural Symbols (Harmondsworth, 1973);Google ScholarImplicit Meanings (London, 1975.Google Scholar On the sociological analysis of science, with reference to its ideas, not just to its professional and social structure, see Barnes, B., Scientific Knowledge and Sociological Theory (London, 1974)Google Scholar and Bloor, D., Knowledge and Social Imagery (London, 1976).Google Scholar For a thorough and masterful treatment and comprehensive bibliography of the social-conceptual barrier in the historiography of the history of science, see Young, R. M., “The Historiographic and Ideological Contexts of the Nineteenth Century Debate on Man's Place in Nature,” in Teich, M. and Young, R. (eds.), Changing Perspectives in the History of Science: Essays in Honour of Joseph Needham (London, 1973), pp. 344–438.Google Scholar On the use of biological metaphors and themes from the sciences as the foundation of theories of society, including functionalism, see Russett, C., The Concept of Equilibrium in American Social Thought (New Haven, 1966);Google ScholarMann, G. (ed.), Biologismus im 19. Jahrhundert, Studien zur Medizingeschichte des neunzehnten Jahrhunderts, Bd. 5 (Stuttgart, 1973).Google Scholar The history of medicine has reflected the conceptual side; the sociology of medicine the institutional and social context. Thus, the former emphasizes theories of disease; the latter stresses professionalization of medical personnel and patients. The closest it comes to the theory of disease is in the notion of “sick role,” which deals with medical behavior, not ideas. See Dreitzel, H. (ed.). The Social Organization of Health Care, Recent Sociology, no. 3 (New York, London, 1971).Google Scholar In his introductory essay, Dreitzel complains of this dichotomization. The collection of papers that follows validates his point. It is a difficult problem, made more apparent even by Dreitzel's careful selection. The recent interest in combining the sociology of professions and the history of medicine can be seen in N., and Parry, J., The Rise of the Medical Profession (London, 1976)Google Scholar and Berlant, J., Profession and Monopoly: A Study of Medicine in the United States and Great Britain (Berkeley, 1975). See also, refs. 5 and 30.Google Scholar

2 Canguilhem, G., La formation du concept de réflexe (Paris, 1955);Google ScholarFiglio, K., “Theories of Perception and the Physiology of Mind in the Late Eighteenth Century,” History of Science, 13 (1975) 177–212;CrossRefGoogle ScholarPubMedFrench, R., Robert Whytt, the Soul, and Medicine, (London, 1969);Google ScholarSmith, R., “The Background of Physiological Psychology in Natural Philosophy,” History of Science, 11 (1973) 75–123.CrossRefGoogle ScholarPubMed Figlio and Smith stress the late eighteenth and nineteenth centuries, and give extensive bibliographies.

3 Illich, I., Medical Nemesis, the Expropriation of Health (London, 1974).Google ScholarHisLimits to Medicine (London, 1976)Google Scholar is an expanded version. Many of the popular critiques of medicine, such as Dubos, R., Man, Medicine, and Environment (Harmondsworth, 1970)Google Scholar and Poynter, N., Medicine and Man (Harmondsworth, 1973), despite cautionary reminders of the state of modern medicine, contain their approach wholly within the presuppositions of scientific medicine; they parade the progressive achievements of science and medicine, so that the present is simply the sum of the past, and thereby encourage the belief in the unchallengable nature of the present. Reference to things gone wrong, such as the disrespect for the environmental impact of man, simply necessitate incorporating another parameter into the accepted scientific world view.Google Scholar

4 Thomas Szasz has repeatedly asserted and defended this thesis with respect to mental deviation redefined as mental illness and the persecution of unacceptable drug, alcohol and stimulant use redefined as illnesses of addiction. See his Ideology and Insanity (Harmondsworth, 1974)Google Scholar and Ceremonial Chemistry, the Ritual Persecution of Drugs, Addicts, and Pushers (London, 1975).Google Scholar Illich rightly claims that we should reject Szasz's separation of the mental from the bodily, and extend the analysis into the heart of medicine. Szasz's division only makes the scientific foundations of medicine more impregnable by setting psychiatry off against medicine as a pseudo-science and ideological weapon. Illich, Medical Nemesis, pp. 117–18.

5 This is, of course, why the sociology of medicine has concentrated so heavily on the “patient role” and on the idea of “negotiation” in the doctor-patient relationship. For a general survey of the sociology of medicine, see Robinson, D., Patients, Practitioners and Medical Care (London, 1973)Google Scholar and Tuckett, D.(ed.),An Introduction to Medical Sociology (London, 1976).Google Scholar The standard monograph is Friedson, E., Profession of Medicine (New York, 1973).Google Scholar On the doctor-patient relationship, see Stimson, G. and Webb, B., Going to See the Doctor (London, 1975).Google Scholar Joan Emerson focused upon the especially tension-ridden aspect of this relationship in her study of the person as individual vs. object during examinations with obvious sexual overtones, “Behavior in Private Places: Sustaining Definitions of Reality in Gynecological Examinations,” in Dreitzel, H. (ed.), Patterns of Communicative Behavior, Recent Sociology no. 2, (New York, London, 1970), pp. 73–97.Google Scholar Of general application is also Goffman, E., “The Medical Model and Mental Hospitalization. Some Notes on the Tinkering Trades,” in hisAsylums (Harmondsworth, 1968), esp. pp. 291–305.Google Scholar For a sensitive treatment of the subtle shifts in the power of the doctor over the patient, see Guggenbühl-Craig, A., Power in the Helping Professions (Zurich, New York, 1971);Google Scholar see also ref. 30. Paul Ramsey insists on an autonomous, ethical perspective on medical activity, and stresses the notion of a “joint adventure” in healing, in his The Patient as Person (New Haven, 1970).Google Scholar

6 Within the context of the history of biological ideas, the key problem is the special nature of vitalism, as opposed to animism, materialism, mechanism, etc. “… Vitalism is the rejection of two metaphysical interpretations of the causes of organic phenomena, animism and mechanism. … Vitalism is merely the recognition of the originality of the vitalfact.” Canguilhem, G., La connaissance de la vie (Paris, 1952), p. 156.Google Scholar The passage is quoted as part of a discussion of Canguilhem in Lecourt, D., Marxism and Epistemology. Bachelard, Canguilhem and Foucault (London, 1975), p. 179.Google Scholar See also Canguilhem, La formation, op. cit. (ref. 2); Figlio, K., “Theories,” op. cit. (ref. 2)Google Scholar, where a bibliography of relevant literature can also be consulted; “The Metaphor of Organization: An Historio- graphical Perspective on the Bio-Medical Sciences of the Early 19th Century,” History of Science, 14 (1976) 17–53.CrossRefGoogle Scholar Foucault speaks of an “epistemic” change in the early nineteenth century, which now saw the notion of life as a presupposition to the ordering of natural beings and which entailed as a major consequence a sharp dividing line between living and non-living. Foucault, M., The Order of Things (London, 1970), esp. pp. 226–32, 263–79.Google Scholar

7 Descartes, R., Treatise of Man (1664), translation and notes by Hall, T. (Cambridge, Mass., 1972), pp. 1–4.Google Scholar For the original, verified French text with commentary, see Alquie, F., Oevres philosophiques de Descartes, 3 vols. (Paris, 1963), 1, pp. 379–480.Google Scholar

8 Stahl, G. E., “Uber den Unterschied zwischen Organismus und Mechanismus,” translated from sections 20–24 of his Dissertatio Inauguralis Medica de Medicina Medicinae Curiosae (Halle, 1714)Google Scholar by Gottlieb, B., in Sudhoffs Klassiker der Medizin 36 (1961), 48–53, 71–3.Google Scholar

9 The classificatory foundations of the animal world, irritability and sensibility, were concepts which signified the degree of animality or perfection of life. They were measures of the faculties of living organisms embedded in the complexity of the nervous system. With the association of life and organization, especially of the nervous system, compara tive anatomy came to the fore as the ultimate biomedical science. See Figlio, K., “Metaphor,” op. cit. (ref. 6);Google ScholarDagognet, F., Le catalogue de la vie, (Paris, 1970);Google ScholarColeman, W., Georges Cuvier, Zoologist (Cambridge, Mass., 1964)CrossRefGoogle Scholar, ch. 4. On the use of comparative anatomy in the establishment of a natural history of man, see Bynum, W., Time's Noblest Off spring: the Problem of Man in the British Natural Historical Sciences, 1800–1863 (Ph.D. dissertation, University of Cambridge, 1974).Google Scholar For a study of the biological, social and theological ramifications of the hierarchy of living nature in the late eighteenth and nineteenth centuries, see Bynum, W., “The Great Chain of Being After Forty Years: an Appraisal,” History of Science, 13 (1975), 1–28.CrossRefGoogle Scholar On the development of the biological vocabulary itself, see my “Theories,” op. cit. (ref. 2). For the extension of this vocabulary into medicine, first as the basis of nosology, then as the foundation of physiological theories of disease defined as deviated function, see Canguilhem, G., Le normal et le pathologique (Paris, 1966).Google Scholar

10 Bichat, X., General Anatomy, translated by Coffyn, C., 2 vols. (London, 1824), esp. “Characteristic Marks of Vital Properties Compared With Those of Physical Properties,” 1, xx-xxx; quote is from pp. xxiii-xxv and the translation is slightly altered.Google Scholar

11 Cuvier, G., La règne animate distribuée d'après son organisation pour servirde base à I'histoire naturelle des animaux et d'introduction à I'anatomie comparée, 4 vols. (Paris, 1817)1, pp. 4–5.Google Scholar

12 Haller, A. von, A Dissertation on the Sensible and Irritable Parts of AnimalsGoogle Scholar, anonymous English translation of S. Tissot's French edition of Haller's studies, with an introduction by Temkin, O., Bulletin of the History of Medicine, 4 (1936), 651–99.Google Scholar Tissot's edition of Haller contains the original dissertation plus a collection of related works by Haller and several other authors. See Tissot, S. A. A. D. (ed.), Mémoire de Haller, 4 vols. (Lausanne, 1756–1760).Google Scholar For a thorough study of Haller, see Toellner, R., Albrecht von Haller, iiber die Einheit im Denken des letzten Universalgelehrten, Sudhoffs Archiv, Beiheft 10 (Wiesbaden, 1971);Google Scholar on sensibility and irritability, pp. 171–82. For the tradition emerging from the Hallerian concepts into 19th century biomedical, anthropological and psychological thought, see ref. 9.

13 Cuvier, G., Leçons d'anatomie comparée, 5 vols. (Paris, 1800–1805), 1 (1800), xxiii.Google Scholar

14 Richerand, A..Nouveaux elemens de physiologie,2voh.(Paris, 1804)1, pp. 116–7;Google ScholarMüller, J., Zur vergleichenden Physiologie des Gesichtsinnes des Menschen (Leipzig, 1826), xix–xxi.Google Scholar Müller opposed the penetration of quiet observation to the ”dangerous gamble” of physiological experimentation. Also, see his Von dem Bediirfnis der Physiologie nach einerphilosophischen Naturbetrachtung (Bonn, 1824)Google Scholar, repr. in Meyer-Abich, A., Biologie der Goethezeit (Stuttgart, 1949), pp. 256–81.Google Scholar For Rudolphi, see duBois-Reymond, E., “Gedachtnisrede auf Johannes Miiller” (1859), in his Reden, duBois-Reymond, Estelle (ed.), 2 vols. (Leipzig, 1912) 1, pp. 135–317;Google Scholar see p. 203. Sir Charles Bell's use of compara tive anatomy was so widespread in his works that a bibliography would be both exces sively long and unnecessary. See Gordon-Taylor, G..Sir Charles Bell, His Life and Times (Edinburgh and London, 1958).Google Scholar For treatments of this theme, see ref. 9, and Temkin, O., “Basic Science, Medicine, and the Romantic Era,” Bulletin of the History of Medicine, 37 (1963), 97–129.Google Scholar Comparative anatomy, the science of “organization,” was extraordinarily versatile in its ability to subsume a variety of apparently opposed philosophical positions about the nature of life. I have developed this idea in “Metaphor,” op. cit. (ref. 6).

15 Cuvier, G., op. cit. (ref. 13), 1.Google Scholar

16 For a fuller consideration of the notion of “phenomenalism” in this sense, and of its implications for the emergence of a specifically physiological vocabulary, conceptual foundation and methodology, see my “Theories,” op. cit. (ref. 2). Also, see June Good- field'snotion of “descriptive” vs. “explanatory” vitalism in her, The Growth of Scientific Physiology (London, 1960),Google Scholar and her, “Some Aspects of English Physiology: 1780–1840,” Journal of the History of Biology 2 (1969) 283–320.CrossRefGoogle Scholar

17 Bichat, X., Physiological Researches on Life and Death, translated by Gold, F., (London, 1815?), p. 21.Google Scholar For a brilliant teasing-out of the implications of this apparently circular definition, and of the relationship between death, disease and degeneration at this time, see Foucault, M., The Birth of the Clinic, translated by Smith, A. Sheridan (London, 1973), pp. 140–6, 154–9.Google Scholar

18 I do not refer to the work of Auguste Comte, whose name is commonly associated with this term, but with the characterization of science which, by the mid-nineteenth century, had risen to dominate its self-image. Among the characteristics, one might include: the unity of knowledge via a “scientific method,” phenomenalism, nominalism, and the insistence upon the separability of fact from value, and therefore, of “science” from philosophy or ideology. See Kolakowski, L., The Positivist Philosophy, translated by Guterman, N. (Harmondsworth, 1972);Google Scholar also, Charlton, D., Positivist Thought in France During the Second Empire, 1852–1870 (Oxford, 1959);Google Scholar on science vs. philosophy as ideology, see D. Lecourt, Marxism, op. cit. (ref. 6). My emphasis on a rising technological attitude is somewhat different from the usual account of positivism, which stresses empiricism and the primacy of the sensually perceived “given.” The technological attitude emphasises instead the manipulation and creation of events. Indeed, knowledge becomes identified with the control imposed by the investigator-technologist to such an extent that knowledge equals control. In a recent study, unknown to me when writing this paper, Paul Hirst draws out a distinction between Bernard's thought and the positivist tradition into which he is usually cast, which is similar to my “technological attitude;” Hirst, P., Durkheim, Bernard and Epistemology (London, 1975).Google Scholar

19 Magendie, F., ”Quelques idées générates sur les phénomènes particuliers aux êtres vivants,” Bulletin des sciences médicates de la société d'émulation 4 (1809) 145–70Google Scholar, see p. 165. Albury, W., “Physiological Explanation in Magendie's Manifesto of 1809,” Bulletin of the History of Medicine, 48 (1974) 90–9.Google ScholarPubMed

20 Ibid., 159.

21 A convenient focus for the comparative anatomical vs. vivisectional approach in the early nineteenth century is the priority dispute between Sir Charles Bell and Francois Magendie over the discovery of spinal nerve root function. Bell's methods inclined toward the former, while Magendie's were unrepentantly vivisectional. Müller said that his experiments were among the crudest imaginable; “Nouvelle experiences sur l'effet que produit l'irritation mécanique et galvanique sur les racines des nerfs spinaux,” Annates des sciences naturelles 23 (1831), 95–112Google Scholar, esp. p. 96. This reaction might, to some extent, explain the German support for Bell, which seems to have been nearly universal. For a partial bibliography, see my “Theories,” op. cit. (ref. 2) and ref. 5. Bernard, Even, Magendie's student, conceded the random nature of Magendie's experiments, De la physiologie generate (Paris, 1872), p. 19.Google Scholar For a general, comparative study of antivivisec- tion movements in Europe and America in the nineteenth century, see Bretschneider, H., Der Streit urn die Vivisektion im19. Jahrhundert, Median in Geschichte und Kultur, no. 2 (Stuttgart, 1962).Google Scholar For Britain, see French, R. D., Anlivivisection and Medical Science in Victorian Society (Princeton, 1975).Google Scholar

22 Bernard, C., La science experimentale (Paris, 1878) 149–218;Google Scholar on this point, p. 202. About Bichat as an intermediate, he said, “… Before him, the philosophical doctrines, animist or vitalist, hovered too high and too far above reality to become the fecund initiators of the science of life. They were only capable of enervating it by playing the role of idle sophisms which then ruled in the school. Bichat, on the contrary, in decentralizing life, in incarnating it in the tissues; has placed them under the dependency of a principle still metaphysical, but less elevated in philosophical dignity; and able to become a scientific basis more accessible to the spirit of research and progress. Bichat, in a word, deceived himself on the theory of life, as his predecessors, the vitalists; but he was not deceived on the physiological method. It is to his glory to have founded it by placing the immediate causes of the phenomena of life in the properties of tissues and organs,” La science experimentale, pp. 161–2. On Bernard's philosophy, see: Hirst, P., op. cit. (ref. I8), chs. 1, 2;Google ScholarVirtanen, R., Claude Bernardand his Place in the History of Ideas (Lincoln, Nebraska, 1960);Google ScholarCharlton, D., op. cit.Google Scholar (ref. 18); Kolakowski, L., Positivist Philosophy (Harmondsworth, 1972), ch. 4;Google ScholarBergson, H., “The Philosophy of Claude Bernard,” extract translated by Klebs, C., Bulletin of the History of Medicine 4 (1936), pp. 15–21;Google ScholarCanguilhem, G., Etudes d'histoire et dephilosophie des sciences (Paris, 1970), pp. 127–71;Google ScholarSchiller, J., Claude Bernard etlesproblemes scientifiques de son temps (Paris, 1967), ch. 12;Google ScholarGrmek, M. (ed.), Cahier de notes, 1850–1860 (Paris, 1965), Bernard's notebook; see Grmek's ref. 153, pp. 243–7 with respect to Bernard and vitalism.Google Scholar

23 Bernard, C., La science, op. cit. (ref. 22) 197;Google Scholar emphasis mine.

24 ”We look for the laws of phenomena, that is to say, what is stable, invariable, permanent, eternal in these phenomena. … Things are not rigorously so in nature; but we are obliged to conceive them so; and to say that it is necessary to have methods of proceeding which are in accord with the nature of things doesn't mean anything, because we do not know the nature of things and these methods must be only in relation to the nature of our mind,” Cahiers de notes, p. 58. ”In saying that life is the directive idea or the developmental force of the living being, we simply mean the idea in the succession of all morphological and chemical changes produced by the germ from the beginning to the end of life. Our minds grasp this unity as a conception which compels acceptance, and we explain it as a force. But it would be wrong to believe that this metaphysical force is active in the manner of a physical force. This conception does not leave the intellectual domain to react on the phenomena for the explanation of which the mind created it,” La science, pp. 210–11, Virtanen's translation. “… The search for first causes is not scientific (see Newton on this subject),” Cahiers, p. 66; also, see Grmek's commentary, pp. 232–3.

25 Bernard, C., Du progres dans les sciences physiologiques (1865), repr. in La science, pp. 37–98.Google Scholar See p. 75 for quote. The association of knowledge with mastery and control can be found throughout Bernard's writings. Once the experimental method was accepted, there would be no more materialism, spiritualism, brute or living matter; only phenomena whose conditions were to be determined. The way around the ontological problems—those of the nature of things-was to recast the problem into an epistemological-methodological form, Du progrès, pp. 55–6, 58, 61, 68, 75, 82–3.

26 Bernard, C., An Introduction to the Study of Experimental Medicine (1865), trans lated by Green, H. (London, 1927; repr. New York, 1957) 28;Google ScholarVirtanen, A., Claude Bernard, op. cit., (ref. 22) ch. 3;Google Scholar on his idea of experimental reason, see An Introduction, Pt. 1, chs. 1,2;La science, pp. 108–9.

27 Bernard, C., “Lectures on Experimental Pathology,” translated and published throughout the Medical Times (1860); quote in 2, 225.Google Scholar

28 Ibid., emphasis mine.

29 The sociological, philosophical and psychological literature on alienation and related themes is immense, but it has not penetrated the critical studies of the history of medicine. I am attempting here to locate points of common interest between the history of medicine and the human sciences, and to suggest the value of each perspective to the other. There was surely a change of consciousness along with the conceptual and social movements analysed here. Medicine touches, indeed invades, all of our lives, and because of its ubiquitous presence, reinforces the consciousness of our very natures; to borrow again from sociology, medicine “mediates” social values. Among the major concerns of sociol ogy today are the socio-economic determinants, not just of living habits, but of selfdefinition. Advanced technology and automation are associated with an objectifying attitude, one which encourages people to treat each other and themselves as things. Technological medicine reinforces such an attitude by its immediate, day-to-day encounter with people already submissive because of need. “Alienation” and “reification” refer to the self-estrangement from an integral unity with the creations of human industry, with one's physical and, ultimately, emotional nature. They imply a disintegration into unrelated, sometimes conflicting parts, each the result of an introjection of a structural feature in the society. Alienation is not necessarily a conscious or painful state, nor is it conspiratorial. But it is there just the same, and one might profitably look at physical illness as the expression of such a state, interpreting the emphasis of modern medicine on physical causes as an implicit and seductive form of social control. Such an approach would provide an interesting tool for historical study of the concepts of disease. For a general, historical overview of alienation, see Schacht, R., Alienation (London, 1971);Google Scholar also, Fromm, E., The Sane Society (Greenwich, Conn., 1955).Google Scholarx Especially relevant with respect to consciousness are: Berger, P. and Pullberg, S., “Reification and the Sociological Critique of Consciousness,” New Left Review 35 (1966) 56–77;Google ScholarBerger, P., Berger, B. and Kellner, H., The Homeless Mind (Harmondsworth, 1974)Google Scholar, which attempts to define “modernity”; Brown, B., Marx, Freud, and the Critique of Everyday Life (New York, London, 1973).Google Scholar J. Habermas deals with the introjection of technological social organization and thought in the formation of the sense of self in his Toward a Rational Society, translated by Shapiro, J. (London, 1971) chs. 4–6;Google Scholar R. Young analyses scientific knowledge and organisation, the most intractable area because of the mediation by science itself of our belief in the objective, value-free, factual nature of reality, in “Science is Social Relations,” Radical Science Journal, no. 5 (1976) 65–129.Google Scholar On health and social control, see Parsons, T., “Definitions of Health and Illness in the Light of American Values and Social Structure,” in his Social Structure and Personality (New York, 1964), pp. 257–91.Google Scholar

30 Temkin, O., “Die Krankheitsauffasung von Hippokrates und Sydenham in ihren ‘Epidemien’,” Sudhoffs Archiv fur die Geschichte der Medizin 20 (1928), 327–52;Google Scholar for a general, historical, but somewhat traditional account of nosology, see Faber, K., Nosog-raphy in Modern Medicine, (London, 1923);Google Scholar for a bibliography of the early nineteenth century literature, see Young, T., An Introduction to Medical Literature Intended as a Guide to Students and an Assistant to Practitioners, 2nd edn. (London, 1823);Google Scholar M. Foucault gives an insightful interpretation of the conceptual preconditions and consequences of the nosological mode of thought in his The Birth of the Clinic, op. cit. (ref. 17) chs. 1–7; similarly for Gusdorf, G., Dieu, la nature, I'homme au siècle des lumières (Paris, 1972) ch. 5, esp. pp. 477–98;Google Scholar also Dagognet, F., Le Catalogue, op. cit. (ref. 9) ch. 3.Google Scholar The authority of hospital medicine facilitated the imposition of abstract, nosological redescriptions of illness. See Waddington, I., “The Role of the Hospital in the Development of Modern Medicine: A Sociological Analysis,” Sociology, 7 (1973) 211–24.CrossRefGoogle Scholar Even outside the hospital, the change at this time from a doctor-patron to a doctor-patient relationship had similar consequences. See Holloway, S., “Medical Education in England, 1830–1858: A Sociological Analysis,” History, 49 (1964) 299–324;CrossRefGoogle ScholarJewson, N., “Medical Knowledge and the Patronage System in Eighteenth Century England,” Sociology, 8 (1974) 369–85;CrossRefGoogle Scholaribid., “The Disappearance of the Sick Man from Medical Cosmology, 1770–1870,” Sociology, 10 (1976) 225–44.CrossRefGoogle Scholar

31 For a summary of all the prominent nosological systems of the eighteenth and early nineteenth centuries, see Vaidy, , “Nosographie,” in the Dictionnaire des sciences médicates, 60 vols. (Paris, 1812–1822) 36 (1819) 206–65;Google Scholar on the analysis of symptoms into combinations of simple, regular elements, see Pinel, P., La médecine clinique, 2nd edn. (Paris, 1804) 1–11;Google Scholaribid., Nosographie philosophique, ou la méthode de l'analyse appliquée a la médecine, 6th edn., 3 vols. (Paris, 1818) 1, i–lxxviij;also, ref. 30.Google Scholar

32 Brown, J., The Elements of Medicine (Philadelphia, 1790 and several later British editions);Google ScholarDarwin, E., Zoonomia; or the Laws of Life, 2 vols. (London, 1794–1796) 2;Google ScholarCullen, W., Works, Thomson, J. (ed.), 2 vols. (Edinburgh, 1827)Google Scholar, includes his Nosology, Physiology and First Lines of the Practice of Physic. In the early nineteenth century, disease did become deviated physiology, but in the sense of an altered state of self- restoring vital properties; Bichat, X., General Anatomy, op. cit. (ref. 10) 1, 1;Google ScholarNacquart, J.-B., ”Medecine agissante,” in the Dictionnaire, op. cit. (ref. 31)31 (1819) 483, 5.Google Scholar But, as the author says, “disease,” “nature,” “curative power of nature” are all abstrac tions, all just names. Thus, while “active medicine” was not yet condoned (p. 487), the emptying-out of special meaning of all the relevant terms was well underway. On this intermediate period of physiological medicine, see Canguilhem, G., Le normal, op. cit. (ref. 9);Google Scholar on the history of the idea of the healing power of nature, see. Neuburger, M., Die Lehre von der Heilkraft der Natur im Wandel der Zeiten (Stuttgart, 1926).Google Scholar

33 The significant question for the cooperative attention of the historian, sociologist and anthropologist is the reflection or mediation of social attitudes toward classes of people, indeed the definition and establishment of classes, in the organisation and running of these hospitals. The hospitals brought medicine to many who would not otherwise have received it, but they also directly brought to bear an ineffable attitudinal environment upon a large number of socio-medically unadapted people and thus helped in the classification of people. The history of hospitals, like the history of medicine as a whole, has not ap proached these questions (but see ref. 30). Attention has been given to mortality, but that primarily by economic historians interested largely in population growth. The “gateways to death” view was argued by Helleiner, K., “The Vital Revolution Reconsidered” (1967), in Glass, D. and Eversley, D. (eds.), Population In History, (London, 1965) p. 84;Google ScholarMckeown, T. and Brown, R., “Medical Evidence Related to English Population Changes in the Eighteenth Century,” Population Studies (11., 1955) 119–41;CrossRefGoogle Scholar the more benign case was put by Sigsworth, E., “Gateways to Death? Medicine, Hospitals and Mortality, 1700–1850,” in Mathias, P. (ed.), Science and Society 1600–1900 (Cambridge 1972), pp. 97–110.Google Scholar For a recent history of the establishment, staffing and running of the British voluntary hospitals, based on detailed studies of hospital records, see Woodward, J., To Do the Sick No Harm, a Study of the British Voluntary Hospital System to 1875 (London, 1974).Google Scholar A classic study, with bibliography, is Burdett, H., Hospitals and Asylums; their Origin, History, Construction, Administration, Management, and Legislation, 4 vols. (London, 1891–1893)Google Scholar. Pinker, R. has compiled statistics from the British hospitals of the second half of the nineteenth and first third of the twentieth centuries, English Hospital Statistics 1861–1938 (London, 1966).Google Scholar This is a companion volume to Abel-Smith, B., The Hospitals, 1800–1948 (London, 1964).Google Scholar A comprehensive hospital history project is underway in Germany; Jetter, D. has produced two volumes so far, Geschichte der Hospitals, 2 vols. (Wiesbaden, 1966–1971).Google Scholar On the social history of hospitals and public health policy, see the several papers by Rosen, G. collected in his From Medical Police to Social Medicine (New York, 1974).Google Scholar

34 Pinel, P., Nosographie, op. cit. (ref. 31) vij.Google Scholar

35 Ibid., lxxiii-lxxiv.

36 It might seem provocative to identify the hospital with a natural history museum, but it does help us gain an insight into the tensions within such a social structure. Nosology and pathological anatomy were the foundations of medicine. The one directed attention toward disease as a natural object; the other toward disease as a natural, and also physical, object. Dagognet, F. has drawn out this comparison; Le catalogue, op. cit. (ref. 9) ch. 3.Google Scholar If we keep in mind that classification was not, and is not, just a logical extension of medicine as scientific theory, but was also socio-political categorisation, then the opportunities for critical history and sociology of medicine are unlimited. “ … A civilisation, by the bias of its codes, ultimately has only the diseases it agrees to maintain (supporter)” Dagognet, p. 9. The French hospitals, according to Dagognet, were spatially organised along nosologi cal lines. The poor law and workhouse infirmeries in Britain were established explicitly, not just for treatment, but for the classification of the various social misfits, from vagrants at one extreme to (acutely physically ill) able-bodied men at the other. The goal of classification is quite clear in the debates on “The Metropolitan Poor Act of 1867, Amended 1869.” See Hansard's, Parliamentary Debates, ser. 3, CXCVIII (London, 1869).Google Scholar By far the largest number of London's hospital beds was provided by these infirmaries in the late nineteenth century. The general hospitals of Paris served the same classificatory function. These extreme examples lead to questions about the more subtle forms of classification operative in all large hospitals, indeed, in the medical system itself. On the socio-political role of the hospital, see Regus, M., “Das Krankenhaus im gesellschaftlichen Widerspruch,” Blatter fur deutsche und Internationale Politik 15 (1972) 1031–52.Google Scholar The difference between illness, which engenders social approval and support, and malingering, which engenders contempt and even criminal prosecution, is a medical decision. Once again, medicine is a mediator of social values, and takes an increasing domain within its jurisdiction. Following social legislation, such as the British workmen's compensation acts in the early twentieth century, treatises on malingering appeared, e.g., Collie, R. J., Malingering and Feigned Sickness (London, 1913,17);Google ScholarLlewellyn, L., Malin gering, or, the Simulation of Disease (London, 1917).Google Scholar The conversion of socio-political and ethical problems into medical ones is what Illich called “the medicalization of life.”

37 This claim was made about Broussais by a Danish student, C. Otto, who visited the Hôtel-Dieu, Paris in 1822. In his words: “It is probably impossible to assist at less instructive hospital visits than these. I don't know if I ought more to disparage or admire the swarm of young people who follow them anyway. The visits take place at 6:30 in the morning. Broussais arrives relatively on time, which is not the case with many of the Parisian hospital physicians. But, in a half-hour, [he] dispatches about 200 patients and crosses the wards at a run (au pas de course). … It is very rare that Broussais designates a patient by his name or that he makes a stop and a few remarks during his brief gallop.” Another student, visiting the Paris hospitals somewhat later, said: “The hospital doctor never considers the individual, but only the patient; for him, his patient is a fact, an object of observation, a cipher; so that the higher, moral and beneficent side of medicine is completely obliterated. …” Benjamin Rush, studying there in the 1830s, was also dissatisfied: “[The student] can indeed frequent the hospitals every morning for about two hours without cost, mixed in a crowd of his colleagues pressed around a professor, and perhaps cast a glance on some patients. … I have experienced the disadvantage of such a procedure along with most of my colleagues who studied with me in these hospitals, and who were unanimousin their complaints on this subject.” From the Lancette in the 1820s: “Look in the wards of the Hotel- Dieu. This crowd which presses around the person of the surgeon, throws itself upon the wretch who has a fracture. All want to produce the crepitation. The patient could not tolerate it; he died of pain. He did not even respond to the fifth student who interrogated him, in order to find out if he had a disease which might inhibit the knitting.” These reports were extracted from an extremely useful documentary history of the Paris clinical school and hospitals by Wiriot, M., L'Enseignement clinique dans les hôpitaux de Paris entre 1794 et 1848 (d'apres documents de L'epoque) (Paris, 1970),Google Scholar the quotes, in order, are from pp. 112, 144, 143, 120. Reports of this sort were numerous. Wiriot also puts second-hand recollections, written late in the nineteenth century, next to first-hand reports of students. In the flattery of the former and the disparity with the latter can be seen the production of the myth of the Paris clinics, which has conditioned the attitudes of modern history of medicine written as an implicit legitimation of modern medicine. See, for example, one of 1899 compared with one of 1822, pp. 111–12. The standard history of Paris hospital medicine at this time is Ackerknecht, E., Medicine at the Paris Hospital 1794–1848 (Baltimore, 1967).Google Scholar It should be read along with Foucault, M., The Birth, op. cit. (ref. 17).Google Scholar

38 Lens, De, “Liberte individuelle,” in the Dictionnaire, op. cit. (ref. 31) 28 (1818) 101;Google Scholar quote on p. 104. In Britain, the rapid development of hospitals had a significant effect on medical ethics. It is consistent with my argument that the emergence of a literature on medical ethics in the nineteenth century had little to do with the treatment of patients. Rather, it was a reaction to the destabilization of the established professional relationships between medical practitioners engendered by conflicts over the rights to practice in hospitals. See Waddington, I., “The Development of Medical Ethics-a Sociological Analysis,” Medical History 19 (1975), 36–51.CrossRefGoogle ScholarPubMed An interesting test case can be found in the “ethical” disputes over the relationship of homeopathy to medicine, which were aired in British medical journals in the 1880s.

39 Ibid. 107.

40 Ibid., 109–10, emphasis mine.

41 The hazy, shifting boundary between malingering, hysteria, neurasthenia, nervous mimicry of disease, organ neuroses and “real organic disease” in the nineteenth and early twentieth centuries will form the basis of a forthcoming study designed to carry this programme further. This is an area of social history, but one which can only be fully appreciated in the context of the history of medicine. On this topic, see J., and Haller, R., The Physician and Sexuality in Victorian America (Urbana, 1974);Google ScholarEntralgo, P. Lain, Doctor and Patient, translated by Partridge, F. (London, 1969), esp. pp. 127–46,Google Scholar where he speaks of “the rebellion of the patient” in the late nineteenth century; for a very enlightening document of the socio-medical nature of “nervousness” and “neurasthenia” in the late nineteenth century, see Krafft-Ebing, R. von, “Nervositat and neurasthenische Zus-tande,”in Nothnagel, H., Specielle Pathologie und Therapie (Wien, 1899) XII.2, 1–210.Google Scholar