Engines of Knowledge from the First Information Age: Medicine and the Hospital

By Hamish Robertson and Joanne Travaglia

Introduction

While we now live in an era marked by the emergence of big data, this is not the first ‘big’ information age but the second. The first big data information age occurred in the early 19th century, developed exponentially with a rapid increase in the collection, storage and analysis of information from a growing number of primary sources. In particular, traditional and new disciplines emerged that began to adopt strategies of knowledge acquisition. New technologies made new ways of seeing possible and acceptable. New types of data became not only permissible but desirable. This was an age of knowledge factories that preceded our now digital computer age but one which set the scene for these later developments.

Matching pace with this earlier surge in analogue data and information was the development of analytical processes associated with quantification in particular, including areas such as applied mathematics and statistics. New forms of abstract and, necessarily, reductive data collection strategies, methods and technologies were created. Many of the professions and disciplines that are now considered the engines of the scientific method developed at this time and were increasingly associated with specific institutional settings such as the university and the research laboratory.

This article is the first in series examining some of the ‘engines’ of knowledge production that developed in this first information period and which continue their relevance into the present. In this piece we want to explore, using medicine as an example, the argument the knowledge factories did not and do not ‘simply’ re-present the natural and social worlds but manufacture specific versions of them, versions that could be understood by specific audiences and via approved values systems.

Containing the field

The hospital, the university and the laboratory delineated the acceptable boundaries of knowledge production, by directing focus and resources to particular topics and methods, and especially by claiming the power to authorize what constituted acceptable knowledge in specific fields and what did not. This process can be seen clearly in the field of medicine, for example, which began to take control of both practitioners and practices in order to legitimize and regulate medicine as a field of endeavour. This produced not only a general field of theory and associated praxis, but an extensible basis for claims to authority in society at large and in forms of knowledge production in particular. Newly arising professions and semi-professions began to follow the models of knowledge construction set out by lawyers and the law over the preceding centuries with an emphasis on the empirical and factual. In short, this period was marked by the development of knowledge ‘factories’ with all the attendant features of formal organisational structures as they are commonly understood today.

The rise of hospital as the location for the practice of the science of medicine reflects this shift. What had, in its origins been a place for the care of the slaves and the poor came to, literally and figuratively, ‘contain’ modern interventional treatment, as well as scientific research and experimentation. In capturing both practice and research, hospitals became an engine of knowledge acquisition as the permissible site for specific activities within specified confines and under particular conditions. In this sense the hospital became a specific territorial claim for and by medicine. The flip side of this was public health where regulatory practices and data collection occurred within the community. Even today public health activities are often located within hospitals and the public health paradigm subordinated to medicine.

The hospital also became a replicable, even transportable, locus for the practice of acute and chronic medicine. The quasi-military look of Nightingale wards, the strict hierarchy of and within the professions, and the subordination of the patient to the whole system, reflected both the military concerns and broader Victorian values of the time. Many hospitals sat, where possible, high above the miasmal lowlands (because germ theory was not yet dominant) and assumed a physical presence and prominence in their local communities. Both their architecture and operational activities reinforced this authority. A secular trope of hygiene and risk replaced the theological one of purity and danger that preceded it.

Moving knowledge creation and transmission to the university system was yet another technique by which medicine turned itself into a profession, as well as a distinct academic discipline. The Scottish and French universities were pioneers in this regard but English and American medicine quickly pursued similar trajectories. Control of the production, interpretation and transmission of knowledge lay at the heart of these systemic changes and epistemic transformations. Johansson and colleagues have argued that medical innovation across the centuries involved a trickle-down effect from the more experimental medicine practiced on the more affluent and prestigious sections of the community. Successful elite medical care gradually became generalized across the profession.

The claims of scientific medicine

Medicine is now considered a science, and historical representations of medicine favour this positioning. However it was not until the 19th century that this representation gained hold, and even then the efficacy and reliability of the ‘science’ of medicine was tenuous. Medicine did not become ‘scientific’ in the modern sense until it acquired control not only over the methods of knowledge production, but also over other forms of practice, thereby establishing itself as the authoritative primary form of intervention on the human body. Medical practice which had begun as a highly individual, local and particular art, became increasingly collective and specifically situated expansionary science.

These economic and cultural claims to authority (what Bourdieu calls a form of capital) were supported by the adoption of the Hippocratic Oath as the Lydian stone of modern medicine. This association implied that the profession was symbolically aligned with safety, certainty and consistency in practice. Yet as historian David Wootton argues, and studies into healthcare quality and safety show, these claims were, and to a significant extent remain, largely aspirational. The addition of technology to the mix brought not new practices but new channels for knowledge production. This was a very gradual strategy, and today we find it hard to imagine just how recently much of this techno-medicine and innovation mantra began to pay off.

The creation of expertise

The accumulation of experts, expertise and information strengthened the characteristic of the hospital as a knowledge factory, one which encompassed numerous smaller engines, including those which generated knowledge about everything from germ theory to the statistical analysis of mortality rates (Florence Nightingale’s often forgotten contribution to the field). From infectious disease the hospital gradually extended its brief to include to chronic diseases, rehabilitation, and innumerable other specialties and subspecialties across disciplines, fields and professional and organizational endeavours. As this shift unfolded, a combined process of clinical specificity (e.g. patient disease progression) and quantitative generalisability emerged (e.g. causes of death). Each specialty became a micro-factory for expert information about cancer, heart disease, neurology and so on. Even the subordinate disciplines like nursing, pharmacy and pathology gradually developed their own specialist knowledge in both tacit and explicit forms.

The ability to produce these kinds of specialised knowledge took on a form of self-authorisation. A legitimate discipline was one which was able to generate, disseminate and advocate for this specialist knowledge. Medicine began path re-writing some of its history in favour of prevailing Victorian values (rationality, objectivity, progress, science and management) while aligning the profession to the growing esteem of science in part through the presence of the white lab coat, which denoted a symbolic and practical shift away from the profession’s lineage of the surgeon/barber. The generativity of science and technology were such that they became, and in large part remain, the driving forces of legitimate knowledge production under modernity.

The knowledge producing ‘expert’ acquired authority and license through a claim to produce certain kinds of knowledge, through processes that were only rarely open to the purview of the layman. Thus expertise became a close correlate of authorized knowledge and practice as the knowledge produced, and the engines and engineers of knowledge acquired status. Disruptors to the knowledge claims of the profession could be viewed as threats to the collective, so much so that those like Simmelweiss who used scientific methods to collect data to argue against the craft practices of their profession (and gender), were completely ostracized.

The objectively excluded

Expertise positions the expert as the official gatekeeper to some particular knowledge domain. The 19th century saw the development of a particular discourse around subjectivity and objectivity that has become an enduring trope. Daston and Gallison have charted the journey of ‘objectivity’ to its status as an epistemic virtue, one which is still used to validate and privilege specific forms of scientific knowledge and knowledge creation methods over others.

In comparison, medicine’s epistemic virtues continue to coalesce around the doctor-patient relationship, which in its idealized form, is considered as a valid engine of knowledge production in and of itself. William Osler developed the clinical ward round a century ago and, with it, the mechanics and the performativity of this approach to clinical knowledge acquisition and transmission. Medicine made and still makes claims to a special one-to-one relationship between the doctor and patient, a claim that is supported by both structure and regulation in most countries. A patient’s discharge from hospital largely remains in the remit of the medical practitioner. And of course the status of the ‘patient’ – including who is and who is not – becomes a signature power of the medical practitioner and the medical system. This requires the emergence of a form of definitional authority along with its concepts, methods and tools.

The medical philosopher Georges Canguilhem, Foucault’s doctoral supervisor, published On the Normal and the Pathological in the mid-1960s, based on his own doctoral research. This explored how medicine’s ideas about what was normal and what was pathological were generated and became modified over time, and more specifically explored whether quantitative knowledge could be reconciled with the individual clinical encounter. Foucault’s own Birth of the Clinic took the large teaching hospital as its platform for examining not only the medical gaze but the broader methodology of knowledge production in and through the clinic. Both showed that the epistemic positions of those who produce and legitimize knowledge can have significant ontological effects.

One example of this is the way in which the taxonomic indexation of diseases, operated as a way of codifying and legitimizing knowledge in a way which, by its very structure, seemed to reproduce the scientific methods of their day. Examples include the International Classification of Diseases (ICD, formalised in 1900) and the Diagnostic and Statistical Manual of Mental Disorders (DSM, first published in 1952), which remain two major contemporary engines of knowledge legitimisation in medicine. One governs the ontological ‘canon’ of physical diseases and the other dictates what is determined a mental illness and what is not. The ICD was preceded by the Bertillon Classification of Causes of Death and the medical statistical research of William Farr and Marc d’Espine.

These types of taxonomies with their Linnaean processes of conceptualizing, naming and classifying of organisms acted not only to capture the ontology of diseases, but to  create medico-social ‘problems’, as Foucault and Illich argued, as a way of increasing power, prestige and authority invested in medicine. Both taxonomies were and are shaped by and reflect socio-cultural ideologies and mores of their era, in particular, but not solely, in relation to gender and ‘gendered’ behaviour (e.g. hysteria), ethnicity/‘race’ (e.g. drapetomania, the pathological desire for freedom shown by slaves in the US) and sexual ‘deviance’ (e.g. homosexuality). Discussions over the blurred social-scientific boundaries of such classifications continue into the present day. Knowledge production quite clearly legitimizes both actions taken and who is acted upon.

Conclusion

Medicine is created by a series of inter-related engines of knowledge which legitimise both the profession and its accepted practices. While these engines have been deliberately aligned to scientific (read objective, quantitative and therefore ‘reliable’) forms of knowledge, this positioning is not now, nor ever has been, unproblematic nor uncontested. The use of scientific methods by the profession (and other critics) against itself, would indicate that the social authority and influence built on the ‘engines of knowledge’ strategy within medicine had one major advantage, in that it could operate in both upwards and downwards.

The hospital became and remains as an approved site for the production of knowledge about health, illness, disease and patients. The twin epistemic strategies of the individual patient encounter and the aggregate, quantified data about both patients and their conditions continue to produce medically approved knowledge. The conflict between these has largely been reconciled by favouring a particular version of scientific medicine, but at its inception in the 19th century, this framework proved enormously beneficial for medicine, the medical profession and the social phenomenon of the hospitals. The locus of the hospital became a valuable site for not only data collection (individual and general) but a site for the production of growing volumes of data and its deployment by an expanding system of experts. It seems clear that authority, both then and now, is hugely enhanced by the capacity to establish a knowledge factory, to generate exclusive expert knowledge and to control its application and oversight.


Categories: Digital Sociology

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