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Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2009;38:622633

The Author 2009; all rights reserved. Advance Access publication 11 May 2009 doi:10.1093/ije/dyp180

REPRINTS AND REFLECTIONS

The disappearance of the sick-man from


medical cosmology, 17701870y
N.D. Jewson

Abstract The sick-man may be said to have disappeared from medical cos-
mology in two related senses during the period 17701870. Firstly,
as control over the means of production of medical knowledge
shifted away from the sick towards medical investigators the uni-
verse of discourse of medical theory changed from that of an inte-
grated conception of the whole person to that of a network of
bonds between microscopical particles. Secondly, as control over
the occupational group of medical investigators was centralized in
the hands of its senior members the plethora of theories and thera-
pies, which had previously afforded the sick-man the opportunity to
negotiate his own treatment, were replaced by a monolithic con-
sensus of opinion imposed from within the community of medical
investigators.

Introduction The Concept of Medical Cosmology


It is the objective of this paper to analyse the chan- Medical cosmologies are basically metaphysical
attempts to circumscribe and define systematically
ging structure of relationships which generated and
the essential nature of the universe of medical dis-
sustained the diverse systems of medical cosmology
course as a whole.1 They are conceptual structures
characteristic of Western European societies during
which constitute the frame of reference within
the period 17701870. The paper will proceed along
which all questions are posed and all answers are
the following lines. Firstly, the notion of medical cos-
offered. Such intellectual gestalt provide those sets
mology is introduced, and those aspects of medical of axioms and assumptions which guide the interests,
cosmologies which are of interest indicated. perceptions, and cognitive processes of medical inves-
Secondly, the concept of the mode of production of tigators. They set out the first principles of problem
medical knowledge is defined. Three specific modes orientation, explanatory strategy, methodology, and
are identified and discussed, viz. Bedside Medicine, acceptable results which are not so much tested as
Hospital Medicine and Laboratory Medicine. Thirdly, celebrated in the intellectual activity of their adher-
the three types of medical cosmology associated with ents. Medical cosmologies are an indispensable first
each of the three modes of production of medical order of relevance and relation which enable their
knowledge are described. Fourthly, a distinction is adherents to make sense of and to act within the
drawn between person and object orientated cosmol- world. They provide an overall definition of the field
ogies in terms of their central organizing concepts. and a preliminary affirmation of its form. Hence
Fifthly, it is suggested that the transition from cosmologies are not only ways of seeing, but also
Bedside Medicine through Hospital Medicine to ways of not seeing. Cosmologies prescribe the visible
Laboratory Medicine was accompanied by a shift in and the invisible, the imaginable and the inconceiv-
cosmological form away from a person orientated able. They exclude in the same moment as they
towards an object orientated cosmology. include.
Cosmologies should not however be conceptualized
as static normative frameworks rather they are
* Jewson ND, The disappearance of the sick-man from medical ongoing sets of possibilities, not so much states of
cosmology, 17701870. Sociology 10, No.2, 225-244. Reprinted knowledge (and ignorance) as ways of knowing
with permission. (and ignoring). It is therefore necessary to examine
y
I am most grateful to Terence J. Johnson for his comments the process whereby a cosmological vision is gener-
upon an earlier draft of this paper. ated, sustained, and developed within a specific

622
THE DISAPPEARANCE OF THE SICK-MAN FROM MEDICAL COSMOLOGY 623

social group. This will be discussed through an ana- Using this set of dimensions, three distinct modes of
lysis of the concept of the mode of production of production of medical knowledge will be identified,
medical knowledge, and the specification of three dis- each of which successively dominated Western
tinct modes of production which successively domi- Europe in the period under review.6 These will be
nated Western European societies in the period termed Bedside Medicine, Hospital Medicine, and
17701870. Laboratory Medicine.7 A description of these three
It is the thesis of this paper that medical cosmolo- modes is contained in Diagram 1. Each mode of pro-
gies may be seen not merely as cultural artefacts, duction was associated with a characteristic system of
lying outside the realms of social discourse, but as cosmology. A description of the major features of
modes of social interaction within the structures of these cosmologies is contained in Diagram 2. The
relationships which surround the production of med- paper will continue with a discussion of the types of
ical knowledge. It is contended that medical cosmol- medical cosmology associated with each of these three
ogies generate, reflect, and project conceptions of modes of intellectual production, followed by an
order and identity in the network of relationships examination of the social structures of innovation of
which constitute the process of innovation in medical which these cosmologies were a part.
knowledge. They function as a medium within and
through which perceptions of self and of others are
expressed, legitimized, and institutionalized. In short Three Types of Cosmology
medical cosmologies are not only statements about Bedside Medicine was the mode of production domi-
the world but are also ways of relating to others in nant in Western Europe at the beginning of the
the world.2 The notion of cosmology as a mode of period covered by this paper. By its very nature
interaction will be discussed through an examination Bedside Medicine was polycentric and polymorphous.
of the part played by medical theories in the negotia- It is therefore somewhat misleading to cite one or two
tion of relationships within the three systems of pro- specific centres of innovation and development as
duction of medical knowledge identified. The concepts
examples. However the leading medical school of
of person and of object orientation of medical cosmol-
the continent in the last third of the 18th century
ogies will be introduced and employed in this
was probably that in and around the University of
analysis.
Edinburgh.8 Elsewhere I have described the system
of production of medical knowledge prevailing in
The Mode of Production of Medical England during this era.9
Knowledge The vision of the sick-man institutionalized within
For the purposes of this paper the mode of production the tenets of Bedside Medicine was that of a con-
of medical knowledge3 will be defined as consisting of scious human totality a viewpoint that transcended,
the following interrelated elements. not merely united, the distinctions of psyche and
(1) a group or class which controls and mobilizes the soma found in modern medicine.10 The two major
means of production of medical knowledge but is growth points of Bedside Medicine were phenomeno-
not itself directly involved in the labour process logical nosology and speculative pathology.11 Both
the patron. activities generated a large number of often mutually
(2) a group or class which, with a greater or lesser contradictory theories, and as a result medical knowl-
degree of relative autonomy, undertakes the pro- edge consisted of a chaotic diversity of schools of
cess of production of medical knowledge by thought. The definition of the field was diffuse and
means of the application of its labour power problematic, disciplinary boundaries weak and amor-
medical investigators. phous. The fundamental premises of the subject were
(3) a set of relations formed in production which a matter of dispute and debate. Rivalry between the
constitute the configuration of interdependence proponents of the various theories was commonly
which bind patrons and medical investigators conducted at the level of personal abuse and dogmatic
a system of patronage. polemic.
(4) raw materials of production4 in this case per- Within this disarray, however, a common set of cos-
ceptions of the essential context within which mological principles may be discerned. Controversy
morbid processes occur and within which expla- centred around differing interpretations of the same
nations and cures must be sought. open ended model of bodily processes. Thus, for
(5) the production process itself the predominant example, despite differences in the specific contents
occupational activity of medical investigators of their theories, nosologists constructed their patho-
carried out by means of theoretical and empirical logical entities according to the same general princi-
techniques expressed within conceptual frame- ple, i.e., by grouping together experientially related
works which determine the questions posed and symptoms. Hence disease was defined in terms of
the solutions contrived. its external and subjective manifestations rather
(6) a product a system of theoretical presentations than its internal and hidden causes. In accordance
of bodily events.5 with this principle diagnosis was founded upon
624 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Diagram 1 Three Modes of Production of Medical Knowledge

Occupational Occupational
role of Task
Medical Source of Perception of of Medical Conceptualization
Patron Investigator Patronage Sick-man Investigator of Illness
Bedside medicine Patient Practitioner Private fees Person Prognosis and Total psychosomatic
therapy disturbance
Hospital medicine State; Clinician Professional Case Diagnosis and Organic lesion
hospital career structure classification
Laboratory State; Scientist Scientific career Cell complex Analysis and Biochemical process
Medicine academy structure explanation

Diagram 2 Medical Cosmologies, 17701870

Bedside Medicine Hospital Medicine Laboratory Medicine


Subject matter of Nosology Total symptom complex Internal organic events Cellular function
Focus of Pathology Systemic dyacrasis Local lesion Physio-chemical
processes
Research Methods Speculation and Statistically oriented Laboratory experiment
inference clinical observation according to scientific
method
Diagnostic Technique Qualitative judgement Physical examination Microscopic examination
before and after death and chemical tests
Therapy Heroic and extensive Sceptical (with the Nihilistic
exception of surgery)
Mind/Body Relation Integrated: psyche and Differentiated: Differentiated: Psychology
soma seen as part Psychiatry a specia- a separate scientific
of same system lized area of clinical discipline
of pathology studies

extrapolation from the patients self report of the if they were of the same order as other phenomena
course of his illness. with which they are already familiar. This foundation
Pathology was speculative, systemic and monistic. of metaphor may become part of the everyday taken-
Medical investigators sought to discover a single for-granted currency of social exchange, and, in the
basic cure for all the ailments known to man. This processes of socialization and interaction, come to be
was achieved by invoking some universal, ontologi- seen as an objective description of the ultimate reali-
cally irreducible, first cause of illness. The study of ties of the medical world.12 In the era of Bedside
proximate and precipitating causes was neglected in Medicine cosmological analogies emphasized an
favour of the elucidation of the general underlying image of the body as a microcosm, a reality sui generis
predisposition to ill health. These morbid forces subject to its own peculiar laws of growth and decay,
were located within the context of the total body comparable to the macrocosm of the physical
system rather than within any particular organ or universe.13
tissue. Furthermore, in addition to physical disposi- A dramatic transformation in the form of medical
tion, all aspects of emotional and spiritual life were cosmology occurred at the Parisian hospital schools
deemed relevant to the understanding of the func- during the first three or four decades of the 19th cen-
tions of the constitution. It was also believed that tury with the introduction of a new mode of produc-
each individual had his own unique pattern of tion of medical knowledge, here termed Hospital
bodily events which the practitioner had to discern Medicine.14 The raw materials of medical theorizing
in each case. The practitioner was expected to adopt now became the innumerable morbid events, occur-
an active therapeutic role, intervening in the patholo- ring within the gross anatomical structures, which
gical processes afflicting his clients through the heavy presented themselves to the clinical gaze on the
application of heroic remedies. crowded wards. Medical investigators concentrated
Medical cosmologies are frequently expressed in the upon the accurate diagnosis and classification of
form of metaphors or analogies, which enable their cases rather than upon the prognosis and therapy of
holders to explain bodily events by treating them as symptom complexes.15 The sick-man became a
THE DISAPPEARANCE OF THE SICK-MAN FROM MEDICAL COSMOLOGY 625

collection of synchronized organs, each with a specia- life, then it must also be the locus of disease. Life
lized function. thus became the process of interaction within and
The four great innovations of Hospital Medicine between the cells, disease a particular form of these
were structural nosology, localized pathology, physical physical and chemical processes. However, despite the
examination and statistical analysis. The major success of the cellular pathology it was not accompa-
achievement of the Parisian School was the delinea- nied by a cellular therapy. Scientific analysis swiftly
tion of objective disease entities by means of correlat- dispatched the traditional remedies but offered few
ing external symptoms with internal lesions.16 alternatives in their place. Nevertheless the founda-
Pathology took the form of a local solidarism, focus- tions were laid for a new kind of clinical medicine.
ing upon specific morbid events within the tissues Scientific medical investigators were equally dissatis-
rather than upon general disturbances of the consti- fied with the speculative systematists and the
tutional system as a whole. Symptoms were demoted pathological anatomists. The first they regarded as
from the status of defining characteristics to that of unscientific and the second they believed had reified
secondary indicators of disease. The surface appear- the concept of disease. All that could actually be dis-
ances were made subservient to the hidden underly- covered in the ailing body were cells disturbed in their
ing causes. Diagnosis were founded upon physical functions. Medical knowledge could only advance
examination of observable organic structures rather therefore as part of a general enquiry into the com-
than verbal analysis of subjectively defined sensations plete range of cellular processes, both normal and
and feelings. This was achieved during life by means abnormal. Clinical diagnosis was reorganized around
of a number of specially invented scopes and after the application of a series of chemical tests of body
death by means of autopsy. Pathological anatomy, substances designed to identify morbid physiological
indeed, became the all pervading research technique processes. Medical practise became an appendage to
of Hospital Medicine. A novel degree of certainty was the laboratory.
introduced into both pathology and diagnosis by the Although the medical investigators of the mid-19th
use of quantitative methods. Statistics quickly dev- century German universities varied in the sophistica-
astated the claims of the traditional materia medica, tion of their theoretical models, all shared a strictly
and ushered in an era of therapeutic scepticism.17 The materialist interpretation of biological phenomena.
new conceptions of disease were accompanied by A crusade was launched to rid biology of all vitalist
radical innovations in medical analogies and meta- concepts. The attention of the medical investigator
phors. Thus, for example, Rostans theory of organi- was directed away from the living totality, away
cism compared the composition and disposition of even from gross anatomical structures, towards the
the organs of the body with the parts of a moving fundamental particles. The search was instituted for
clock. Once in motion both clockwork and living the ultimate units of analysis rather than the highest
organisms run out their cycles according to inexorable levels of synthesis. Thus the analogy chosen by
mechanical laws.18 Schwann to illustrate the cellular theory was drawn
Laboratory Medicine was first established within the from the realms of organic chemistry. He argued that,
German university system in the middle decades of even if there is no actual relation between the process
the 19th century.19 The transformation in cosmology of crystal formation and cell formation, they are of
precipitated by this innovation was founded upon the the same order of phenomena.21
application of the concepts and methods of natural
science to the solution of medical problems.20 The Person and Object Orientated Cosmologies
two major areas of development were histology and The concepts of person and object orientation refer to
physiology. Numerous discoveries concerning the the basic organizing assumptions embedded within a
properties of tissues were organized into a coherent cosmology.22 From this point of view cosmologies
synthesis by the cell theory. The latter proposed that may be regarded as constellations of meanings, gen-
the ultimate structural and developmental units of all erated within the structure of relationships which
living animals and plants are the cells. Following the constitute the mode of production of medical knowl-
announcement of this theory intensive studies were edge. The form of the cosmology is a function of the
made of the processes of cellular function and repro- form of the role structure within which it emerges.
duction. Progress in physiology was largely the result Person and object orientated cosmologies are thus
of the deliberate introduction of the theories and systems of meaning assigned to medical events
techniques of physics into the study of living organ- within two distinctive types of interactional network.
isms, pioneered by a small group of young scientists Role systems may be distinguished in terms of their
at the University of Berlin. decision making processes. A person orientated role
Pathology also was totally reconstituted. It was system is one in which judgements about others are
asserted that observational anatomy would never made in terms of the individual attributes of persons
explain the causes of disease. Hence the new pathol- rather than their formal statuses, decisions being
ogy was built upon the findings of experimental phy- open to negotiation and discussion between the mem-
siology. Since the cell was the fundamental unit of bers of the group on the basis of their particularistic
626 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

ideas and interests. Members attain their location in organization of medical innovation in each of the
the role system through a process of mutual explora- three modes of production identified above.
tion of personal identities. Formal definition and seg- In the era of Bedside Medicine the patron consisted
regation of roles is low, and members operate with a of a small coterie of patients drawn from the ruling
high range of verbal and behavioural alternatives. In class. The role of medical investigator was not differ-
this situation cosmology takes a form which facilitates entiated from that of practitioner to any significant
the elucidation of the individual needs and desires of extent. Hence the relations of production were
the members of the role system. Medical cosmology formed in private practice and centred around the
conceives its universe of discourse to be composed of collection of fees by medical personnel from the
acting and responsive beings.23 Life, death, and dis- sick. In this situation the political and economic
ease are conceptualized as mysterious and enigmatic power of patrons insured that they retained ultimate
events, attributable to some inscrutable agency sub- control over medical investigators and the process of
ject to its own peculiar vital principles. Medicine con- production of medical knowledge.24 It was the sick
sists of the study of the functioning of this life-force. person who decided upon the efficacy of his cure
Ambiguity and ambivalence are commonplace in this and the suitability of his practitioner. Hence practi-
type of role structure, and person orientated cosmol- tioners, and thus medical investigators, formulated
ogies sensitize actors to its presence. Cosmologies of their definitions and explications of illness so as to
this kind afford a wide range of alternatives for the accord with the expectations of their clients. The lat-
expression and realization of meanings, each indivi- ters particularistic felt needs directed the course of
dual tending to evolve his own particularistic percep- development of pathology and nosology. Thus it is
tion of his body-self. The ideational form of medical through an analysis of the controls generated by the
cosmology facilitates the exploration of the plurality dominance of the patient within the consultative rela-
of options available in this situation. The contempla- tionship that the peculiar structure of the cosmology
tion of the life-force is a task suited to philosophical characteristic of Bedside Medicine may be explained.
speculation and is in principle open to differing The social structure of Bedside Medicine consisted of
interpretations. a network of segmental, unregulated patient-practi-
In contrast an object orientated role system is one in tioner relationships. Medical investigators were frag-
which decision making processes are invested in the mented into numerous local groups, each dedicated to
formal status of the members. Persons relate to one the service of one part of this small but multifaceted
another in terms of the social categories to which they medical market and each ranked according to the
belong, i.e., as if they were things or objects. There is social standing of their patrons. The various shades
a clear separation of roles, the powers and privileges and grades of practitioners offered a wide selection
accorded to each being precisely and generally desig- of theories and therapies to the sick. In the absence
nated. Verbal and other behavioural alternatives are of reliable professional, academic or technical criteria,
defined by the rules of etiquette which govern inter- patients selected their practitioners by means of their
action between roles. Medical cosmology is structured own personal assessment of the moral integrity and
in such a way as to reinforce the ascribed relations professional skill of medical personnel. The consulta-
between the formal categories which its adherents tive relationship was thus joined on the basis of per-
represent. Cosmological form disparages the explora- sonal empathy between the parties. The sick-man
tion of individual motive and intention, sensitizing its sought to penetrate behind the practitioners public
adherents to the presence of collective order. The performance in order to assess the veracity of the
study of medicine is focused upon the recurring, latters claim to occupational competence and integ-
objective, quantitative characteristics of categories of rity. The medical practitioner, on the other hand, won
the sick rather than upon the unique, subjective, qua-
the favours of his patron by individually proving his
litative differences between individuals. The universe
personal and professional suitability in the context of
of medical discourse is seen to be composed of inan-
a primary face-to-face relationship. He sought to dis-
imate objects. Living organisms and their ailments are
cover the particularistic requirements of his patient in
conceptualized as law-like combinations of non-living
order to satisfy them to the exclusion of his ubiqui-
elements and substances, life and death as physico-
tous professional rivals. This delicate process of
chemical processes. The study of life is replaced by the
mutual exploration was conducted through a variety
study of organic matter.
of verbal and extra-verbal channels of communica-
tion. Hence the consultative relationship was wide ran-
From Person to Object Orientated Cosmology ging, founded upon the elucidation of numerous
The eclipse of Bedside Medicine by first Hospital and social competences in addition to the capacity to
then Laboratory Medicine represented a shift away administer and consume therapeutic nostrums. Social
from a person orientated toward an object orientated interaction took the form of an interpretive and infer-
cosmology. This assertion will be demonstrated by ential analysis of motives and intentions, in which
an examination of the relationship between the idea- both parties sought to maximize their respective advan-
tional form of medical cosmology and the social tage by probing the individual qualities of the other.
THE DISAPPEARANCE OF THE SICK-MAN FROM MEDICAL COSMOLOGY 627

Theories and therapies played an important part in organization of Bedside Medicine stimulated the pro-
this process of presentation of self between the sick duction of innumerable superficial novelties each
and medical personnel. The successful medical inno- derived from a common set of assumptions a char-
vator was one whose theories offered the patient a acteristic blend of individual display and popular con-
recognizable and authentic image of his complaint servatism. The apparent confusion, ambiguity, and
as he experienced it. At the same time the practitioner the interminable controversy of Bedside Medicine
sought medical theories which offered him the oppor- were not a function of crisis within medical cosmol-
tunity to dramatize his special healing powers and ogy but rather a key feature of its normal operation.
thus distinguish him from his ubiquitous rivals. In In the era of Bedside Medicine, then, social interac-
the context of these constraints a person orientated tion within the consultative relationship consisted of
cosmology was generated characterized by two major a complex process of calling forth, testing, and mana-
features. ging personal identities. This exchange of confidences
Firstly, the necessity of achieving personal rapport in took place, in part, through the medium of medical
the consultative relationship encouraged medical knowledge itself. In effect the contemporary concepts
investigators to give prominence in their theories to of nosology and pathology facilitated a dialogue
a conception of the sickperson as an integrated between the sick and medical personnel which
psycho-somatic totality. The person of the patient in served the purposes of each by elucidating informa-
all his aspects remained the focal point of medical tion concerning the personal qualities of the other.
knowledge. The sick-mans subjective experience of Hospital Medicine represented the first major step
his symptoms were the raw materials from which towards the institutionalization of an object orien-
the pathological entities of medical theory were con- tated medical cosmology. Two aspects of this transfor-
structed. His perception of himself as a unique indi- mation will be identified and discussed. Firstly, at the
vidual with specific personal problems of physical and same time as the sick-man found himself unequivoc-
mental health were reflected in the enormous variety ably subordinated to the medical investigator, the
of pathological conditions generated by the phenom- focus of medical knowledge moved away from the
enological nosology. His lack of demarcation between person of the former towards esoteric entities defined
physical and emotional disturbance was mirrored by in accordance with the perceptions of the latter.
the integration of physiological and psychological Secondly, as control over the occupational group of
forces in contemporary theory and therapy. His obses- medical investigators was centralized in the hands
sive search for relief from his pains and hope of a of its senior members the profusion of speculative
recovery were matched by the sweeping claims of systems characteristic of Bedside Medicine was
the array of heroic remedies accompanying each replaced by an ongoing consensus upon matters of
system of pathology. Thus in effect the patient theory and therapy.
appeared in the cosmology of Bedside Medicine in a During the Revolution the traditional institutions of
guise similar to that in which he appeared to himself, medical innovation, associated with the ancien
i.e., as an individual and indivisible entity. regime, were suppressed and (after an interval
Secondly, the constraints of the career system direc- during which they too were abolished) the hospitals
ted the creative imagination of medical investigators were reconstituted at the centre of the French medical
towards individual interpretation of the basic canons system. A two tier system of medical practice was
of medical theory. Consequently Bedside Medicine devised in which hospital clinicians became the new
was characterized by a large number of competing elite of the profession. The thousands of poor and
and mutually exclusive systems, all of which could destitute sick housed within the hospitals had little
claim legitimate descent from the generally accepted opportunity to exercise control over the activities of
principles of medical cosmology. Occupational success the medical staff. The powerlessness of the patients,
was dependent upon the ability to attract the interest combined with an enormous size of the hospital
and approval of a client or patron. Medical men system, provided the clinicians with an inexhaustible
sought to advertise their services by means of the fund of acquiescent research material. Clinicians thus
allure of their own personal collection of speculations gained control over and autonomy within the techni-
and concoctions. It was necessary for their theories to cal process of production of medical knowledge. A
be sufficiently familiar to accord with the ideologies collegiate system of occupational control had
and expectations of the sick, whilst simultaneously emerged within the community of medical
sufficiently exotic to hold out an exclusive and com- investigators.25
pelling promise of cure. This multiplicity of interpre- Hospital Medicine was thus based upon a new type
tations upon a common theme was sustained by the of relation between the sick-man and the medical
number and variety of potential audiences which investigator. Interaction between clinicians and hospi-
were open to the medical investigator. A range of tal patients was organized around a nexus of formally
overlapping and interlocking subcultures among the defined statuses and strictly prescribed patterns of
affluent sick sustained an equally various assortment deference. Henceforth the medical investigator was
of theories and therapies. Hence the social accorded respect on the basis of the authority
628 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

inherent in his occupational role rather than on the Bedside Medicine discoveries were best kept as trade
basis of his individually proven worth. The public secrets to be exploited in the consultative relationship.
guarantee of the safety and efficacy of theories and Hospital Medicine, however, constrained medical
therapies no longer rested upon the patients approval investigators to make available their findings rapidly
of their contents, but upon the social status of their and openly to their occupational peers in the hope of
authors and advocates. The new occupational stand- attracting the attention of influential leaders of the
ing of the clinician was matched by the emergence of profession. A battery of medical journals and societies
a new role for the sick-man, that of patient. As such established at the Parisian school in the second and
he was designated a passive and uncritical role in the third decades of the 19th century provided the institu-
consultative relationship, his main function being to tional channels of this new type of career system.26
endure and to wait. Access to these communication outlets was con-
These social realignments were reflected within the trolled by the same group which presided over the
cosmological system of Hospital Medicine. At the allocation of appointments. Hence it was relatively
centre of the new medical problematic was the con- easy for senior members of the occupational group
cept of disease. Interest in the unique qualities of the to impose a strong commitment to common theoreti-
whole person evaporated to be replaced by studies of cal assumptions and technical procedures throughout
specific organic lesions and malfunctions. Diseases the community of medical investigators. Thus the
became a precise and objectively identifiable event number of supportive audiences available to the med-
occurring within the tissues, of which the patient ical investigator dwindled to one, and the market for
might be unaware. The fundamental realities of speculative reinterpretations of cosmological princi-
pathological analysis shifted from the total body ples disappeared. The centralization of power within
system to the specialized anatomical structures. The the occupational community heralded the imposition
experiential manifestations of disease, which had pre- of a cosmological form which made the controversies
viously been the very stuff of illness, now were of Bedside Medicine redundant. Ambiguity and con-
demoted to the role of secondary signs. The patients fusion were replaced by certainty and order.
interest in prognosis and therapy was eclipsed by the Furthermore, relieved of the necessity of laying
clinicians concern with diagnosis and pathology. The claim to the understanding of each and every ailment
special qualities of the individual case were swallowed clinicians were free to introduce a new division of
up in vast statistical surveys. In short the sick-man labour into the process of medical investigation.
was no longer regarded as a singular synthesis of Occupational subgroups began to concentrate their
meaningful sensations. Instead the sick in general gaze exclusively upon specific anatomical structures,
were perceived as a unitary medium within which each applying the same general cosmologically pre-
diseases were manifested. The consultative relation- scribed rules of theory and method.27 As a result
ship took the form of a processing exercise in which the integrated conception of body functions character-
the ambiguity and individuality of each case was sys- istic of Bedside Medicine was superceded by the frag-
tematically eliminated by the application of fore- mented and partial images of a host of specialisms.
known diagnostic procedures, the function of which The three dimensional space of the body had been
was to allocate the patient to a category within the redefined. The evolution of medical specialization,
nosological system. It was as a member of that cate- then, was not so much dependent upon the accumu-
gory, i.e., as a suitable case for treatment, that he lation of factual knowledge as upon the generation of
conducted the remainder of his relationship with his a cosmology which permitted the application of inten-
practitioner. sive effort to the study of limited and circumscribed
As medical investigators gained power over the con- diseases and regions of the body.
ditions of their own recruitment, education and prac- Thus the emergence of Hospital Medicine severed
tise they became a much more homogeneous the link between the concepts of medical theory and
occupational group. A unified system of intellectual the naive experiences of sufferers from disease.
conduct could now be enforced throughout the Medical cosmology no longer served as a two-way
system of production and distribution of medical channel for the elucidation of personal qualities.
knowledge by medical investigators themselves. Instead the cosmological system of Hospital
Medical investigators obtained their posts through a Medicine institutionalized a set of hierarchical status
system of selection which was under the direct con- differentials between the sick and medical investiga-
trol of senior members of the occupational group. tors and among medical men themselves.
Henceforth, therefore, the distribution of resources A new phase in the emergence of an object orien-
and rewards depended less upon the satisfaction of tated cosmology opened with the development of
the patient than upon recognition among professional Laboratory Medicine. Two major aspects of
peers. The focal point of a career in medical innova- Laboratory Medicine will be discussed here. Firstly,
tion shifted away from the network of primary rela- whereas under Hospital Medicine the direction of
tionships with the sick toward a network of secondary the power differential between the sick and medical
relationships with other clinicians. In the era of personnel had been reversed, under Laboratory
THE DISAPPEARANCE OF THE SICK-MAN FROM MEDICAL COSMOLOGY 629

Medicine the patient was removed from the medical Indeed the scientific revolution in medical knowledge
investigators field of saliency altogether. This increase may be said to have undermined the very existence of
in the social distance between the sick and medical medicine as a distinct discipline in its own right.
investigators was accompanied by a relocation of the Medicine ceased to be a subject defined by its explicit
fundamental realities of pathology in microscopical and exclusive contents, and became instead an
events beyond the tangible detection of patients and applied science, consisting of a pragmatically derived
practitioners alike. Secondly, whereas Hospital range of disciplines and techniques, distinguished by
Medicine had celebrated the interests and perceptions its specific purpose.
of clinicians, Laboratory Medicine was founded upon The realignment of the boundaries of the medical
the world-view of the scientific research worker. This investigators quest were but one part of a general
transformation precipitated a total reconstruction of metamorphosis of work tasks characteristic of the
the epistemological foundations of medicine as a shift from Hospital to Laboratory Medicine. The occu-
field of knowledge. pational activity of medical investigators henceforth
The introduction of Laboratory Medicine to German took the form of the extension of certified knowledge
society may be illustrated by the example of Prussia.28 rather than the servicing of clients. The authority of
The role of patron was undertaken by a unifying and the research worker was a function of his capacity to
modernizing state. Though bitterly resented by local manipulate abstract symbols and concepts. A study of
elites which had previously controlled the universities, the emergence of occupations based on scientific
in the early 19th century the Prussian state centralized knowledge must take cognisance of this transforma-
the academic selection procedures and played a far tion which is rooted in the nature of the activity itself.
greater role in evaluating candidates. This policy was This development represented a significant gain in the
intended to improve German national prestige and social detachment of the medical investigator from
power within European society. Hence university per- the sick. It enabled him to conceptualize the sick-
sonnel likely to attain a continental reputation for man as a material thing to be analysed, and disease
their contributions to the advance of knowledge, as a physico-chemical process to be explained accord-
rather than a local reputation of their pedagogic or ing to the blind inexorable laws of natural science.
therapeutic skills, were adopted as proteges by the Thus whilst Hospital Medicine had dissolved the inte-
Ministry of Education. In this manner a new breed grated vision of the whole man into a network of
of laboratory based medical investigators was created. anatomical structures, Laboratory Medicine, by focus-
Two distinct, and often mutually hostile, career sys- ing attention on the fundamental particles of organic
tems emerged: that of research worker and that of matter, went still further in eradicating the person of
medical practitioner. The former monopolized access the patient from medical discourse.
to the laboratory facilities which rapidly became the This increase in social distance was accompanied by
essential means of production of the new medicine. the erection of strong boundaries between the sick
Research workers grew into a self conscious and self and medical investigators. Indeed the character of
confident elite, whose distinctive occupational ideol- social relationships in the era of Laboratory
ogy emphasized the value of scientific work for its Medicine gave the community of medical investiga-
own sake irrespective of its practical applications. tors the appearance of an insulated intellectual
The state, wishing to detach itself from the centrifugal cocoon. Specifications for membership were exacting
forces asserted by local interest, increasingly relied and exclusive. Significant communication about
upon the advice of the leaders of the scientific com- the causes and cures of illness was confined to the
munity when distributing rewards and resources for members of the group, legitimate publication outlets
intellectual endeavour. Thus, by making use of the being reduced to a closely guarded few. The use
state machine, medical investigators were enabled to of technical jargon and concepts served as a ritual
assert the primacy of their disciplinary interests over mode of differentiation between the established and
institutional, educational and professional ones.29 the outsiders.
The conceptualization of sickness and health devel- The centralized homogeneous system of occupa-
oped by the early 19th century French clinicians had tional control existing within the scientific commu-
been limited by the exigencies of their occupational nity insured that the same set of cognitive maps
task, which restricted their gaze to morbid events and methodological prescriptions were adopted by
occurring within gross anatomical structures. The all medical investigators. Novelties which earned
imagination and curiosity of laboratory scientists their authors rewards were those which extended
were not bound within these restrictions, however.30 and articulated established principles rather than
For them the study of illness became part of a much challenged and reformed them. This is not to suggest
wider investigation into the organization and func- that the cosmology of Laboratory Medicine was static
tions of organic matter.31 Morbid events were no but rather that the ongoing development of its poten-
longer regarded as a discrete area of enquiry but tialities occurred at the level of specification rather
were studied in the context of a general analysis of than interpretation. Thus the primary mode of devel-
both normal and abnormal physiological processes. opment of medical knowledge became the creation of
630 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

new specialisms rather than the reinterpretation of exchanges. The work situation of the medical investi-
dominant cosmological concepts.32 However speciali- gator thus restricted his involvement with the object
zation in the era of Laboratory Medicine was consti- of study i.e., the suffering of the sick and dying to
tuted upon quite different epistemological its extrinsic utility in obtaining career objectives.
foundations to that of Hospital Medicine. The division Hence the research workers intellectual detachment
of intellectual labour was based not upon the injunc- was a function of his ulterior occupational
tion to study particular organs and diseases but upon motivation.33
the conceptual demarcations derived from scientific The career struggle among medical investigators was
disciplines. Thus, for example, the problems encoun- fought out through the manipulation and appropria-
tered in medical practice rapidly declined as a legiti- tion of scientific knowledge, the patterns of intellec-
mate point of departure for the discourse of medical tual property rights playing a key part in determining
investigators. the patterns of deference shown in interaction among
Ben-David and his followers have seen in the pro- occupational peers. The formal organization of the
cess of differentiation of knowledge into specialities medical cosmology of Laboratory Medicine provided
and sub-fields the key to the extraordinary creativity a vehicle for the institutionalization and reinforce-
of 19th century German science. Ben-David argues ment of a range of status obligations and role iden-
that a fierce struggle for career rewards within the tities within the scientific community. Thus the
university departments constrained the young and process of innovation in medical knowledge was
the ambitious to innovate by means of launching inspired by a belief in and a search for a single
new fields of study. When these disciplines had rational order in both the physiological processes of
matured and been institutionalized within the aca- organic matter and the social inequalities among
demic system the pioneers were first in line to collect medical investigators.
the chairs and institutes that accompanied scientific
success. At the same time Ben-David also emphasizes
that the decentralized pluralistic structure of the
German university system facilitated this process of
subject fission. Turner has pointed out however that
Conclusion
more significant than the mere intensity of competi- This paper has attempted to formulate an albeit brief
tion was a shift towards a new kind of competition and incomplete sketch of one or two of the concepts
dominated by cosmopolitan and disciplinary, rather which, it is hoped, may prove fruitful in the socio-
than local and institutional, criteria. logical explanation of changes in the perception and
This new kind of occupational competition created a conceptualization of the human body by medical per-
new pattern of relationships among medical investi- sonnel during the course of the industrialization of
gators. The scope of occupationally relevant role per- western societies. Many important aspects of such a
formance was henceforth narrowly and specifically study have been neglected or glossed over here of
defined. Occupational activity took a form comparable course. Thus, for example, no analysis has been
to a game situation in which precisely identified made of the processes of change within and between
objects are manipulated within a closely prescribed modes of production of medical knowledge; no refer-
area of play according to imposed, universalistic and ence has been made to the interaction between the
impersonal sets of rules. Medical investigators production of medical knowledge and other types of
accounted for themselves in stereotyped and formal cultural endeavour; no examination has been made of
modes of communication which encouraged the the relationship between intellectual production and
expression of moral qualities or biographical particu- other practices within the social formation, such as
lars. Occupational competence was evaluated accord- the economy and polity; and so on. Attention has
ing to foreknown and general standards. This is in been drawn, however, to the changing appearance
sharp contrast to Bedside Medicine in which occupa- of the sick-man within pathological theory and to
tional activity took the form of the manipulation of the changing relationship between the sick-man
nebulous and elusive personal identities within an ill- and medical investigators. In the era of Bedside
defined area of play around negotiated, ad hoc, and Medicine the sick themselves determined the course
particularistic sets of expectations. In Bedside of medical knowledge. The student was under
Medicine the medical investigator had sustained an the control of the object of study. The triumph of
ambiguous multifaceted relationship with the sick- blind physico-chemical law over the idiosyncratic
man; in Laboratory Medicine the medical investigator personal experience of the sick-man within the world-
maintained a clear-cut monodimensional relationship view of the medical investigator did not occur
with his occupational peers. Not only had the persona until the latter had achieved a degree of detachment
of the audience altered, but also the form of the rela- from the demands of the sick.34 This increase in social
tionship. In Laboratory Medicine the interaction distance may be discussed in the context of transfor-
between research worker and audience was reduced mations in the relations of production of medical
to a circumscribed network of limited and specific knowledge.
THE DISAPPEARANCE OF THE SICK-MAN FROM MEDICAL COSMOLOGY 631

8
Notes Relatively little modern historical or sociological
1 work has been done on the medicine of the
The notion of medical cosmology bears a close
Scottish Enlightenment, though there has been
resemblance to Althussers problematic, see
recent interest in the science of the period, see for
L. Althusser and E. Bailbar, Reading Capital (trans.
example Hist. Sci. Vol. 12, Part 2, No. 16, June 1974,
Ben Brewster, New Left Books, London,1970) esp.
articles by J.B. Morrell, Reflections on the History
pp. 258, and also L. Althusser, For Marx (trans,
of Scottish Science; S. Shapin, The Audience for
Ben Brewster, Allen Lane, The Penguin Press,
Science in Eighteenth Century Edinburgh; J.R.R.
1971). In recent years a number of authors have
Christie, The Origins and Development of the
formulated comparable concepts. Thus Walton
Scottish Scientific Community 16801760. From a
and Gamble have remarked on the similarity
between Althussers problematic and Kuhns growing literature on this subject the following are
paradigm, P. Walton and A. Gamble, From also of particular interest, J.B. Morrell, The
Alienation to Surplus Value (Sheed and Ward, University of Edinburgh in the late Eighteenth
London, 1972), p. 111. Parallel ideas are to be Century: Its Scientific Eminence and Academic
found in Brodieus intellectual field, Foucaults Structure, Isis, 62 (1971), pp. 15871; S. Shapin,
discursive formation, Bernsteins use of code, Property, Patronage and the Politics of Science:
and so on. None of these terms have been adopted The Founding of The Royal Society of Edinburgh,
here, however, in order to avoid responsibility for B.J Hist. Sc,i vii (1974), pp. 12241, J.R.R. Christie,
and discussion of the wider theoretical contexts The Rise and Fall of Scottish Science, in M.
within which they are located. Crossland, (ed) The Emergence of Science in Western
2
Cf. Goffmans analysis of the part played by the Europe (MacMillan Press, London, 1975). On med-
medical model of mental illness in the interaction icine itself see A.C. Chitnis, Medical Eduction in
between psychiatrists and the inmates of mental Edinburgh 17901820 and Some Victorian
hospitals, E. Goffman, Asylums (Penguin Books, Consequences, Med. Hist., Vol. XVII, April 1973,
1968) pp. 281336. No. 2; V.B. Bullough, The Causes of the Scottish
3
The concept of the mode of production of knowl- Medical Renaissance of the Eighteenth Century,
edge raises fundamental theoretical issues that Bull. Hist. Med., 1971, Vol. LXV, No. 1. Useful his-
cannot be pursued in the present context. Recent torical sources include: A.C. Grant, The Story of the
interest in the notion has been stimulated by the University of Edinburgh During Its First Three Hundred
work of Althusser and Balibar, op. cit.. To conceive Years, (London, 1884, 2 vols.): J.D. Comrie, A History
Marxs philosophy in its specificity is . . . to conceive of Scottish Medicine, (2 vols., 2nd ed., London, 1932).
knowledge as production, Reading Capital, p. 34). It should perhaps be noted that in some respects
The analysis offered in this paper however in no the Edinburgh School was unrepresentative of
way could or would claim to be Althusserian. Bedside Medicine in that it incorporated such
4
It should be noted, after Althusser, that the raw apparently advanced or modern elements as clin-
materials of intellectual production are never ical facilities, training in practical skills, relatively
direct sense impressions of an objective given real- high integration of physic and surgery, instruction
ity. Raw materials consist of ideas, observations, in natural science, etc. However it is suggested that,
intuitions etc. that are themselves the outcome of when considered as a cosmological totality,
previous productive transformations. Edinburgh stands out as the last of the great
5 schools of Bedside Medicine. Thus, for example,
Cosmology is a concept which refers to the totality
of theoretical and empirical activity, and therefore on the significance of the 18th century clinical
embraces elements (4), (5) and (6) in their facilities at Edinburgh see M. Foucault, The Birth
entirety. of the Clinic, (trans. A.M. Sheridan Smith,
6
It should be noted that it is not being asserted that Tavistock Publications, London, 1973), chapter 4.
9
each of the Western European societies discussed N.D. Jewson, Medical Knowledge and the
developed each of these modes of production in a Patronage System in 18th Century England,
determinate sequence of development. Rather it is Sociology, Vol. 8, No. 3, Sept. 1974, pp. 36985.
10
suggested that the medical world of Western Cf. Merleau-Pontys notion of the body-subject,
Europe as a whole was dominated by each of M. Merleau-Ponty, The Phenomenology of Perception,
these modes of production in turn, and that (Routledge and Kegan Paul, London, 1962).
11
during the periods indicated particular medical General discussion of the theories of Bedside
schools represented the leading example of the Medicine may be found in: L.S. King, The Medical
mode then dominant. World of the 18th Century (Chicago, Chicago
7
This nomenclature has been widely used by Univerfsity Press, 1958); L.S. King, George
medical historians. However the terms are rarely Cheyne, Mirror of Eighteenth Century Medicine,
defined in a systematic manner or associated with Bu., Hist. Med. Vol. 48, No. 4, Winter 1974, pp.
the concept of the mode of production of 51739; T.B. Brown, From Mechanism to Vitalism
knowledge. in Eighteenth Century England, J. Hist. Biol., Vol. 7,
632 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

No. 2 (Fall 1974) pp. 179216; W.R. LeFanu, The both patients and other practitioners as a result of
Lost Half Century in English Medicine, Bull. Hist. the promotion of the hospitals after the Revolution.
Med., Vol. XLVI, 1972, pp. 31949; J. Schiller In an era without anaesthetic and antiseptic tech-
Queries, Answers and Unsolved Problems in niques the new range of major operations were
Eighteenth Century Biology, Hist. Sci. xii (1974) invariably agonizing and fatal. That they were
pp. 18499; G.S. Rousseau, Sowing the Wind and attempted at all is evidence of the remarkable
Reaping The Whirlwind: Aspects of Change in 18th transformation of the doctor/patient relationship.
Century Medicine, in P.K. Korshin, Studies in See E.W. Ackerknecht, op. cit., Chap. XII.
18
Revolution: Aspects of Change in English For a description of Rostans views see T.S. Hall
Intellectual History 16401800. (London: The Ideas of Life and Matter (2 vols. Chicago, University
Scolar Press, 1972). L.J. Rather, Mind and Body in of Chicago Press, 1969), Vol. 2., pp. 251254.
19
Eighteenth Century Medicine (London Wellcome C.A.T. Bilroth, The Medical Sciences in the German
Historical Medical Library, 1965). Universities, (MacMillan, New York, 1924);
12
On metaphor see; W.A. Shibles, Metaphor, A. Flexner, Medical Education: A Comparative Study,
(Language Press, White Water Wisconsin, 1971); (MacMillan, New York, 1925); A. Flexner,
D. Schon, Displacement of Concepts (Tavistock Universities: American, English, German, (Oxford
Publications, London 1963). University Press, 1930); J. Ben-David, op. cit., chap-
13
See, for example, the system of pathology invented ter 7; J. Ben-David, Scientific Productivity and
by the Scottish physician John Brown: G.B. Risse, Academic Organization in 19th Century Medicine,
The Bronian System of Medicine: Its Theoretical A.S.R., Vol. 25, (1960) pp. 82343; E. Mendelsohn,
and Practical Implications, Clio Medica, Vol. 5. The Emergence of Science as a Profession in 19th
1970 pp. 4551; G.B. Risse, The Quest for Century Europe, in K.B. Hill (ed.) The Management
Certainty in Medicine: From Browns System of of Scientists, (Beacon Press, Boston, 1964); D.M.
Medicine in France, Bull. Hist. Med., Vol. XLV, No. Knight, German Science in the Romantic Period,
1, 1971, pp. 113. and W.F. Farrar, Science and the German
14
On the rise of Hospital Medicine in France see; M. University System, in M. Crossland op.cit.
20
Foucault, op.cit. E.W. Ackerknecht, Medicine at the On the development of medical knowledge in mid-
Paris Hospital 17741848 (John Hopkins Press, 19th century Germany see; E. Mendelsohn, Physical
Baltimore, 1967); I. Waddington, The Role of the Orders and Physiological Concepts: Explanation in
Hospital in the Development of Modern Medicine: 19th Century Biology, B.J. Hist. Sci., Vol. 2, No. 7
A Sociological Analysis, Sociology, Vol. 7, No. 2, May 1965; E. Mendelsohn, Cell Theory and the
1973, pp. 22124; G. Rosen, Hospitals, Medical Development of General Physiology, Archivs Int.
Care and Social Policy in the French Revolution, dHist. Sci., 1963, No. 65; E. Mendelsohn, Biological
Bull. Hist. Med., Vol. XXX, 1956, pp. 12449; G. Forces in the 19th Century: Some Problems and
Rosen, The Philosophy of Ideology and the Sources, Hist. Sci. Vol. 3, 1964; F. Schiller,
Emergence of Modern Medicine in France, Bull, Concepts of Stroke Before and After Virchow,
Hist. Med. Vol. 20 (1946) pp. 32839; L.S. King, Med. Hist., Vol. 14, 1970; F. Schiller, Physiologys
Medical Philosophy 18361844, in L.G. Stevenson Struggle for Independence in the First Half of the
and R. R. Multhauf, (ed), Medicine, Science and Nineteenth Century, Hist. Sci. Vol. 7, 1968; E.W.
Culture (John Hopkins Press, Baltimore, 1968~) Ackerknecht, Cellular Theory and Therapeutics,
pp. 14359; E.W. Ackerknecht, Elisha Barlett and Clio Medica, Vol. 5 No. 7 April 1970; E.W.
the Philosophy of the Paris School, Bull. Hist. Med., Ackerknecht, Rudolf Virchow Doctor, Statesman,
Vol, 24 (1950), pp. 4360; J. Ben-David, The Anthropologist, (Madison, University of Wisconsin
Scientists Role in Society; A Comparative Survey Press, 1953); L.J. Rather, Disease, Life and Man:
(Prentice Hall, New Jersey, 1971), chapter 6; Selected Essays by Rudolph Virchow, Introduction by
R. Fox, Enterprise and the Patronage of L.J. Rather (Stanford University Press, Stanford
Research in France 180070, Minerva, XI (1973), 1959); E. Benton, Vitalism in 19th Century
pp. 44273. Scientific Thought: A Typology and Reassessment,
15
CF. Foucaults point that Bedside Medicine related Stud. Hist. Phil. Sci., Vol. 5, No.1, 1974 pp. 1748; D.H.
to health whereas Hospital Medicine related to Galaty, The Philosophical Basis of mid-19th Century
normality. M. Foucault, op.cit., p.35. German Reductionism, J. Hist. Med., Vol xxix, No. 3,
16
The mood of the new medicine was caught per- July 1974, pp. 295316; M. Teich, On the Historical
fectly in Georgets remark, You should paint dis- Foundations of Modern Biochemistry, Clio Medica
eases rather [than] diseased people. E.W. Vol. I, 1965, pp. 418; T.O. Lipman, Vitalism and
Ackernecht, op.cit., p. xi. Reductionism in Liebigs Physiological Thought,
17
The only exception to the trend towards therapeutic Isis, Vol. 58, 1967; P.M.H. Mazumdar, Johannes
restraint was in surgery, where new and radical Muller on the Blood, the Lymph, and the Chyle,
operations were devised and carried out. Surgeons Isis, vol. 66, No. 232 June 1975, pp. 24253.
21
had acquired greater power and autonomy vis-a`-vis T.S. Hall, op.cit. p.265.
THE DISAPPEARANCE OF THE SICK-MAN FROM MEDICAL COSMOLOGY 633

22
The concepts of object and person orientation are something other than consciousness of existing
derived from Bernstiens work on socio-linguistic practise, that it really represents something without
codes, see B. Bernstein, Class, Codes and Control, representing something real; from now on con-
Vol.1 (Routledge and Kegan Paul, London, 1971) sciousness is in a position to emancipate itself
pp. 133, 1656, 1847. The interest of Bernsteins from the world and proceed to the formation of
analysis lies in his attempt to explore how sym- pure theory . . . K. Marx and F. Engels, The
bolic systems are both the realizations and regula- German Ideology, (Lawrence and Wishart, London,
tors of the structure of social relationships, op. cit., 1970) pp. 5151.
31
p.194. However, the notions of person and object For an analysis of the contrasting worldviews of
orientation are not necessarily used in this paper in present-day scientists and practitioners see P.
the same manner as Bernstein has employed them Elliott, Professional Ideology and Social
elsewhere. Situation, The Sociological Review Vol. 21, No. 2,
23
On concepts of life and matter see T.S. Hall, op. cit. May 1973, pp. 21128.
32
esp. 36582. Cf. The mode of scientific innovation M.J. Mulkay
24
In terms of the very useful typology of systems of terms branching in Three Models of Scientific
occupational control proposed by T.J. Johnson, Development The Sociological Review Vol. 23, No. 3
Professions and Power, (London, Macmillan, 1972) August 1975, pp. 509526.
33
this situation may be described as one of oligarchic It is not suggested, of course, that the medical
patronage (see chapter 5). investigators of Laboratory Medicine were any
25
See T.J. Johnson, op. cit. Chap. 4. more inhumane, or even instrumentally orientated,
26
See E.W. Ackerknecht, op. cit., (1967) chapter IX. than those of Bedside Medicine. Rather the form of
27
See E.W. Ackerknecht, op. cit., (1967) chapter XIV. the relationships in which they were located con-
28
See R.S. Turner, The Growth of Professional strained them to act, think, and feel in character-
Research in Prussia 18181848: Causes and istic ways.
34
Consequences, Historical Studies in the Physical Cf. N. Elias, Problems of Involvement and
Sciences, Vol. 3, 1971, pp. 13752. Detachment, B.J.S., VII, 1956, pp. 226252.
29
In terms of Johnsons typology of systems of occu-
pational control, cosmopolitan mediation, op. cit., Biographical note; N.D. Jewson: B.Sc. Econ., University
chapter 6. College of Cardiff 1967; M.A. Sociology, University of
30
Division of labour only becomes truly such from Leicester 1968; Lecturer in Department of Sociology,
the moment when a division of material and University of Leicester since 1969.
mental labour appears . . . From this moment
onwards consciousness can flatter itself that it is

Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2009;38:633636
The Author 2009; all rights reserved. Advance Access publication 11 May 2009 doi:10.1093/ije/dyp181

Commentary: The appearance of new medical


cosmologies and the re-appearance of sick and
healthy men and women: a comment on the
merits of social theorizing
Sarah Nettleton

Accepted 29 April 2008

Published 32 years ago in the British Sociological Cosmology, 177018701 is something of a classic.
Associations journal Sociology, Nick Jewsons paper A search using the Thomson ISI Web of Knowledge
The Disappearance of the Sick-Man from Medical Service reveals that, within this database, the article
has some 133 citations and rate of citations have
Department of Sociology, University of York, Heslington, York remained consistent over time. Furthermore, the
Y010 5DD, UK. E-mail: sjn2@york.ac.uk impact is not limited to sociology; the top six subject

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