Practice and the Science of Medicine in the Nineteenth Century Author(s): By Michael Worboys Source: Isis, Vol.

. 102, No. 1 (March 2011), pp. 109-115 Published by: The University of Chicago Press on behalf of The History of Science Society Stable URL: http://www.jstor.org/stable/10.1086/658660 . Accessed: 10/04/2013 18:48
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Practice and the Science of Medicine in the Nineteenth Century

By Michael Worboys*

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ABSTRACT

A generation ago the nineteenth century was at the heart of medical historical scholarship, as the era when modern medicine was born. Over the last decade or so things have changed: other centuries vie for center stage, and former key turning points, like hospital medicine and laboratory medicine, are now seen in terms of continuities on longer timescales. But though chronologically reframed, the modes of medicine still appear chiey at the level of programmatic intentions, including rhetorical uses of science. This essay argues that work in this vein needs to be complemented with equal attention to the performative aspects of practicein the clinic, in the laboratory, and in the eldand that historians of medicine still have much to learn from the practice turn in the history of science.

N 1985 JOHN HARLEY WARNER reviewed the history of science in medicine in America in Osiris; a decade later he reected on the matter again in the same journal.1 In both articles he focused on the nineteenth century, which was then at the heart of medical historical scholarship because it seemed to many historians to be the era in which modern medicine was born. Spurred by the intellectual legacy of Michel Foucault, they explored key themes such as the development of hospital medicine, laboratory medicine, public health, and the rise of the asylum. At the same time, the new social history of medicine was opening previously neglected areas, such as alternative medicine, gender, antivivisection, patients, and the history of the body.2 Over the last decade or so things

* Centre for the History of Science, Technology, and Medicine (CHSTM), Simon Building, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom; Michael.Worboys@manchester.ac.uk. 1 John Harley Warner, Science in Medicine, Osiris, 1985, 2nd Ser., 1:37 85; and Warner, The History of Science and the Sciences of Medicine, ibid., 1995, 2nd Ser., 10:164 193. See also Warner, Ideals of Science and Their Discontents in Late Nineteenth-Century American Medicine, Isis, 1991, 82:454 478. 2 For work inspired by Foucault see Colin Jones and Roy Porter, eds., Reassessing Foucault: Power, Medicine, and the Body (London: Routledge, 1994); Michael Durey, The Return of the Plague: British Society and the Cholera, 18312 (New York: Humanities, 1979); and Andrew Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Lane, 1979). For work in the social history of medicine see N. D. Richards and John Woodward, eds., Health Care and Popular Medicine in NineteenthCentury England: Essays in the Social History of Medicine (New York: Holmes & Meier, 1977); Richard D. Isis, 2011, 102:109 115 2011 by The History of Science Society. All rights reserved. 0021-1753/2011/10201-0006$10.00 109

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seem to have changed. While many historians of medicine continue to work on the nineteenth century, they do so with seemingly less conviction about its pivotal position. Perhaps the centurys richest seams have been worked out, while other centuries beckon; perhaps the vogue for closer focus in period, place, and range has shifted attention from what seemed the big issues. Historians of medicine have certainly been affected by the wider cultural turn and by the fact that they increasingly inhabit history departments rather than working alongside historians of science or in medical schools.3 In this review, I look at how the history of science in medicine in the nineteenth century has fared in these becalmed historiographical waters and suggest that the potential of exploring the practice of science in medicine has yet to be realized, especially with regard to its performative aspects. Indeed, it is surprising that historians of medicine have lagged in adopting the practice turn, since the contiguous subjects of history of science and science and technology studies (STS) have been to the fore in this development. This is not to say that there is no work in this vein in the history of medicine. Malcolm Nicolson made this point in his review of John Pickstones edited collection on medical innovations, pointing out that many historians had been mangling well before Andrew Pickering set out his project.4 But rst we need some context, so let us go back a quarter of a century and consider Warners rst insightful review. His starting point was George Sartons caution that the historian of medicine who imagines that he is ipso facto a historian of science, is laboring under a gross delusion. The point had new relevance because up to the 1970s many historians of medicine had in fact tended to focus on science in medicine, especially discoveries in human anatomy and physiology, the etiology of diseases, and new methods of disease prevention and treatment. But by 1985 the tide was running against this oeuvre. Warner observed that a growing proportion of those who study the new history of health care have more to talk about with historians of the city, women, social welfare, political culture, demography, or labor than they do with historians of the sciences. Note that the reference here is to the history of health care, not even to the fashionable British term social history of medicinewhich in retaining the word medicine conceded too much, some thought, to whiggish, doctor-centered, science-focused histories. Such developments prompted concern that as the eld was colonized by historians without training or background in medicine or science, interest in clinical practice and medical science would wane. Erwin Ackerknecht cautioned that medicine was being left out of the new histories and even that those who have embraced the newer historiography have tended to look at science more than into it.5 Warners prescription for science in medicine was for historians to investigate meanFrench, Antivivisection and Medical Science in Victorian Society (Princeton, N.J.: Princeton Univ. Press, 1975); Roy Porter, The Patients View: Doing Medical History from Below, Theory and Society, 1985, 14:175198; and Roger Cooter, ed., Studies in the History of Alternative Medicine (Basingstoke, Hampshire: Macmillan, 1988). 3 A recent collection on the historiography of medicine had little to say directly on science in medicine. For an up-to-date review see Frank Huisman and John Harley Warner, eds., Locating Medical History: The Stories and Their Meanings (Baltimore: Johns Hopkins Univ. Press, 2004). 4 Malcolm Nicolson, Medical Innovations: Historiography, Heterogeneity, and The Mangle of Practice, Social Studies of Science, 1996, 26:863 874; he was reviewing John V. Pickstone, ed., Medical Innovations in Historical Perspective (Basingstoke, Hampshire: Macmillan, 1992). For work focusing on practice see Andrew Pickering, The Mangle of Practice: Time, Agency, and Science (Chicago: Univ. Chicago Press, 1995); and Karin Knorr Cetina, Theodore R. Schatzki, and Eike von Savigny, eds., The Practice Turn in Contemporary Theory (London: Routledge, 2000). 5 Warner, Science in Medicine (cit. n. 1), pp. 37, 48.

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ings, taking their methodological cues from investigations of medicines wider role in shaping cultural values and social orderfor example, gender roles, hygienic ideas, and notions of normality. But two common assumptions had to be rejected: rst, that meanings were important only because science had had limited practical utility for medicine or benet to patients; and second, that historians had to choose between the social and the scientic roles of ideas and practices. Warner maintained instead that the utility of science how it worked for doctors and patients had to be assessed historically, as he demonstrated so well in The Therapeutic Perspective (1986), and that knowledge could serve the clinic as well as the wider society.6 His principal point was that science in nineteenth-century American medicine had multiple meanings, which varied over time and between groups. Thus, it was just as important to look at the meanings of science in alternative medicine, where empiricism was linked to the democratization of knowledge, as at its meanings in laboratory investigations, where special sites, long training, and esoteric terms seemed necessarily linked to expertise, exclusivity, and hierarchies. Bill Bynum responded to the new agendas of the social history of medicine in his book Science and the Practice of Medicine in the Nineteenth Century (1994). He welcomed many of its features but regretted the fashion to discount the content of past scientic theories and stress their rhetorical uses. He argued that scientic knowledge had been particularly important in three areas of medical practice: the creation of the third estate of research; the transformation of the public face of medicine through high-prole discoveries; and the development of new approaches, tools, materials, and measurements that changed the prevention, diagnosis, management, and treatment of disease. Bynum stressed the importance of science in medicine for the whole nineteenth century, not just the second half and the link with laboratory science.7 In demonstrating these points, he produced a narrative that, by his own admission, had a whiggish avor of great men, discoveries, and inventions. Nonetheless, these developments were situated professionally, socially, and politically, and his extensive bibliographical essay gave his readers the resources further to contextualize the developments in questionthough it was still hard to gauge how they were taken up and used in everyday practice or how they impacted on patients. Bynum might also have warned of the dangers of selective quotation in assessing the rhetorics of science and medicine. Such was the diversity of medicine and the opportunities for outpourings in celebrations and annual addresses that all shades of opinion might be found at any moment and rapid changes in short periods. For example, the British medical elite who delivered reections on Queen Victorias reign, at the jubilee and centennial celebrations and at her death, selected different themes and made very different points about the character of nineteenth-century medicine.8 Ten years on, in 1995, Warner was more sanguine about science in medicine, identifying new areas and approaches that had enriched the eld. There was a growing recognition of the range of sciences, including eld sciences such as epidemiology, sanitary science, and medical geography, as well as those of the laboratory. He also noted

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6 John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820 1885 (Cambridge, Mass.: Harvard Univ. Press, 1986). 7 William F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge Univ. Press, 1994), p. xi. For a work that stresses the link with laboratory science see Andrew Cunningham and Perry Williams, The Laboratory Revolution in Medicine (Cambridge: Cambridge Univ. Press, 1992). 8 Michael Worboys, British Medicine and Its Past at Queen Victorias Jubilees and the 1900 Centennial, Medical History, 2001, 45:461 482.

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the practice turn in the history of science and STS, exemplied by Gerald Geisons The Private Science of Louis Pasteur.9 Interestingly, Warner noted that Geisons book had been received largely as history of science, though a key part was concerned with the development and use of anthrax and rabies vaccines, arguably the rst medical breakthrough of the modern era, matched only in the (long) nineteenth century by Edward Jenner and smallpox vaccination. Geisons main focus was on the translation of laboratory notes into published papers and the presentation of experimental and clinical results to scientic, clinical, and public audiences. But though the performative aspects of Pasteurs work are described and discussed, these are secondary; the focus is on textstheir readings, meanings, and reception. Warners The Therapeutic Perspective is similar and exemplies a behavioral approach, using patient records to map changes in doctors language of illness and treatment regimes.10 There is some attention to the performance of diagnosis and treatment, especially in the illustrative case histories, but the main focus is on rationales and meanings, not hands-on practice. It seems to me that this is typical of much recent and current writing on medical history, including my own. Investigations of practice have been mostly about intentions and projects, about Why? rather than How? There is room for more work on physicalities and materialities and their interactions with mentalities and socialities. This is true for history of medicine in all periods, and it can add a new dimension to our analyses of science in medicine in the nineteenth century. In my book Spreading Germs (2000), I set out to write a history of the germ theory of disease in late nineteenth-century Britain, including means of knowing and acting upon germs.11 My approach was quite high level, looking at the interests and work of veterinarians, surgeons, public health doctors, and physicians, and I included little on everyday practice. I focused on new procedures such as antisepsis, disinfection, and isolation, which were targeted at the ways germs passed between and into bodies. Furthermore, in charting how approaches to prevention and treatment moved from being inclusive and multifactorial to being exclusive and focused on single factors, I gave relatively little attention to the techniques, methods, and operation of germ management in the clinic, laboratory, and eld. My reasoning was in part pragmaticI had a lot to cover; but it was also historiographicalI was writing a medical history of germs and wanted to situate iconic innovations, such as antiseptic surgery and bacteriological methods, in the context of the wider interests and work of my four groups. I now know that I missed a trick with regard to all of my themes: I could, and should, have said more about the performative aspects of the germ practicesthat is, the techniques, materials, and methods of germ management. Attention to performance would have enabled me to show how theories, practices, and meanings were co-produced by germists and how the actors combined elements, both old and new, from sciences, technologies, medicine, and wider sociocultural resources. The nearest I came to recognizing the importance of the performative aspects of practice was in a discussion of operations performed under the carbolic acid spray in the early years of

9 John M. Eyler, Victorian Social Medicine: The Ideas and Methods of William Farr (Baltimore: Johns Hopkins Univ. Press, 1979); Nicolaas Rupke, ed., Medical Geography in Historical Perspective (Medical History, Suppl. 20) (London: Wellcome Trust Centre for the History of Medicine, 2000); and Gerald L. Geison, The Private Science of Louis Pasteur (Princeton, N.J.: Princeton Univ. Press, 1995). 10 Warner, Therapeutic Perspective (cit. n. 6). 11 Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 18651900 (Cambridge: Cambridge Univ. Press, 2000).

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antiseptic practice, where I argued that the theater of such operations manifested putrefactive germ theory and was iconic for the style of surgery and type of surgeon that Joseph Lister sought to create. A good example of the embeddedness of science in clinical practice can be found in Listers series of articles published over many months in 1867: On a New Method of Treating Compound Fracture, Abscesses, etc. In addition to setting out new ideas and practices, the descriptions were workshop manuals for those who wished to emulate and perform his methods. For example, in the nal article, published in July 1867, Lister showed how the fracture wound method described in previous weeks could be adapted to the treatment of abscesses; the aim was to exclude living particles from without. Detailed descriptions of common surgical craft procedures were set alongside principles drawn from many areas of science and illustrated with the obligatory case history. The surgical techniques were unexceptional draining the abscess, applying dressings, and monitoring healing but the accounts were informed by knowledge and know-how from anatomy, pathophysiology, chemistry, materials science, and, needless to say, Pasteurs work on the germ theory of putrefaction. Listers account considered the structure and function of the tissue in which the abscess had developed, combining anatomical knowledge and clinical experience. While he did not speculate on the exciting cause of the abscess, he drew on standard ideas as to how the accumulation of uid would lead to pressure in tissues, which in turn would lead to inammation and an abscess. Drainage was adopted to reduce pressure and, hence, inammation, but the germ theory of putrefaction suggested that this simple operation was dangerous. Without new precautions, living particles would come into contact with the damaged tissues and produce sepsis. Their exclusion was achieved through the antiseptic powers of carbolic acid, mixed with linseed oil and carbonate of lime to make a exible paste dressing; this was in fact glaziers putty . . . with the addition of a little carbolic acid, which surgeons could shape to any wound.12 In this case, the dressing was to be carried on a thin tin plate, which would not react with the mixture, could also be shaped, and would prevent evaporation of the volatile antiseptic. How many times surgeons should drain abscesses and change dressings was to be judged from their observations on the local condition of the wound and the constitutional progress of the patient. Lister was certainly basing his work on Pasteurs germ theory of putrefaction, though this is not cited directly; however, he was also drawing on ideas and techniques from other areas of the natural sciences, from the common stock of surgical and medical understandings of anatomy, physiology, and pathology, from the natural history of case histories, and from what Victorians would have called the practical arts. The theory was embodied in the management of the abscess and dressings in the performance of antiseptic surgery. Alternatively, it was one aspect of a complex construction, improvised from previous constructions, and open to appreciation by medical men less interested in germs than was Lister.13 Indeed, the contributions that followed Listers in the same July 1867 issue of the Lancet show a similar mix of experience, craft, and new science. John Bishop, a

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12 Joseph Lister, On a New Method of Treating Compound Fracture, Abscesses, etc., Lancet, 1867, i:326 327, 357359, 387389, 507509, ii:9596; the quotations are from p. 95 of the last installment. On Lister and the communication of antiseptic methods see Jennifer J. Connor and John T. H. Connor, Being Lister: Ethos and Victorian Medical Discourse, Medical Humanities, 2008, 34:310. 13 Christopher Lawrence and Richard Dixey, Practising on Principle: Joseph Lister and the Germ Theories of Disease, in Medical Theory, Surgical Practice: Studies in the History of Surgery, ed. Lawrence (New York: Routledge, 1992), pp. 153215.

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scientically informed surgeon, combined the work of Euler, Duhamel, and Helmholtz on acoustics with knowledge of the anatomy of the ear to speculate on the origins of a particular condition, the dangers of quack remedies, and the need for aural surgery to be put on a more scientic footing. The next piece was by Thomas Lauder Brunton, then a rst-year house physician at the Royal Edinburgh Inrmary (and yet to travel in Europe for three years, studying pharmacology in Vienna and Berlin and working with Carl Ludwig). His article described the use of amyl nitrite in the treatment of angina pectoris, drawing on his experience with an unspecied but no doubt small number of cases. He starts with his clinical experience in using the accepted remedies of digitalis, aconite, and lobelia, and then chloroform, all aided by venesection or cupping. He states that the inconsistent and disappointing results led him to try amyl nitrite, which had been shown by Benjamin Ward Richardson to be a nerve and capillary relaxant in frogs and identied by Arthur Gamgee as an arterial relaxant in animals and humans. Like Gamgee, Brunton used instrumentsthe sphygmomanometer and hemodynamometerto monitor his patients and wrote that it was necessary to take away a few ounces of blood because patients tended to become plethoric.14 Recent biographies have also been very revealing of the performative dimension of science in medicine. Christoph Gradmanns exemplary study of key innovations in Robert Kochs career, because it emphasizes bacteriology as technology, shows the importance of demonstrations and how it was essential to detail techniques and materials. For Victorian Britain, we have Terri Romanos book on John Burdon Sandersons career and Stephanie Snows account of John Snows work on anesthesia. Romano sees her narrative as emphasizing scientic practice over the construction of theories as she considers Sandersons work as a medical ofcer of health, in private and hospital practice, as a research consultant, and, nally, as Regius Professor at Oxford.15 In these various roles and sites, Sanderson pulls together knowledges, technologies, and techniques to rene instruments like the sphygmomanometer, to reveal the intimate pathology of contagia, and to resolve the mechanisms by which the Venus ytrap rapidly closes its leaves. It would have been useful to have heard more on perhaps Sandersons most important work, the 1873 publication of the Handbook for the Physiological Laboratory, which he edited and coauthored with Edward Klein, Michael Foster, and Thomas Lauder Brunton.16 Like many such texts of the era, including the earliest texts on bacteriology, it was essentially a workshop manual, offering guidance on the performance of laboratory procedures. Stephanie Snow does for anesthesia in Britain what Martin Pernick did for America, detailing the context of the innovation and its relation to professional ideals and the negotiation of clinical encounters. She says much more about anesthetic practice, how-

14 John Bishop, On the Pathology of Tinnitus Aurum, Lancet, 1867, ii:67 68, 96 97; and T. Lauder Brunton, On the Use of Nitrite of Amyl in the Treatment of Angina Pectoris, ibid., pp. 9798, on p. 98. On Bishop see Robert Hunt, Bishop, John (17971873), rev. Christian Kerslake, in Oxford Dictionary of National Biography (Oxford: Oxford Univ. Press, 2004), available at http://www.oxforddnb.com/view/article/2472 (accessed 17 June 2010); on Brunton see J. A. Gunn, Brunton, Sir Thomas Lauder, First Baronet (1844 1916), rev. M. P. Earles, ibid., available at http://www.oxforddnb.com/view/article/32139 (accessed 17 June 2010). 15 Christoph Gradmann, Laboratory Disease: Robert Kochs Medical Bacteriology (Baltimore: Johns Hopkins Univ. Press, 2009); Terri M. Romano, Making Medicine Scientic: John Burdon Sanderson and the Culture of Victorian Science (Baltimore: Johns Hopkins Univ. Press, 2002), p. 6; and Stephanie J. Snow, Operations without Pain: The Practice and Science of Anaesthesia in Victorian Britain (Basingstoke, Hampshire: Palgrave Macmillan, 2006). 16 John Burdon Sanderson, ed., Handbook for the Physiological Laboratory, by E. Klein, Sanderson, Michael Foster, and T. Lauder Brunton (London: J. & A. Churchill, 1873).

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ever, showing how John Snows knowledge of chemistry and physiology, and his experiments on animals, enabled him to develop anesthetic apparatus and a mode of specialist practice that were science based. By contrast, James Simpson, the Edinburgh obstetrician, is shown to have learned from experience. He applied ether to a handkerchief or a cloth that he held over the patients face, exerting variable pressure; and he claimed that only through this physical contact and close observation could one effectively monitor and judge dosage. What was literally a hands-on approach led him to develop a body of medical knowledge and a clinical identity rather different from Snows.17 Of course, Snow was an accomplished clinician as well as an investigator, and Simpson no mere empiric, but the contrast should once again alert us to the multiple dimensions of practice and the intricate relations between crafts and scienceand the rhetorics thereof.18 My suggestion for histories of science in medicine in the nineteenth century is that the complex relations of different kinds of knowledge and practice still need to be explored, not just through programmatic statements, or generalizations about the successions of bedside, hospital, and laboratory medicine, but through studies of performance in the clinic as well as in the laboratory and the eld. We need more such studies, and especially comparisons across sites and times, if we are to understand how the performance of scientic work, both research and routine, was variously commingled with the casework of medical lives and what meanings different practices had for specic groups.19
17 Snow, Operations without Pain (cit. n. 15), pp. 74 92 (discussing the practice of John Snow and James Simpson); and Martin Pernick, A Calculus of Suffering: Pain, Professionalism, and Anesthesia in NineteenthCentury America (New York: Columbia Univ. Press, 1985). 18 John V. Pickstone, Ways of Knowing: A New History of Science, Technology, and Medicine (Manchester: Manchester Univ. Press, 2000; Chicago: Univ. Chicago Press, 2001). 19 For an excellent example of the value of exploring everyday practice see Steven M. Stowe, Doctoring the South: Southern Physicians and Everyday Medicine in the Mid-Nineteenth Century (Chapel Hill: Univ. North Carolina Press, 2004).

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