Thomas Schlich

Biomedical Conventions and Regulatory Objectivity: A Few Introductory Remarks

This special issue of Social Studies of Science centers on the topic of regulation in medicine and, in particular, on the notion of regulatory objectivity, defined as a new form of objectivity in biomedicine that generates conventions and norms through concerted programs of action based on the use of a variety of systems for the collective production of evidence. The papers in the special issue suggest ways in which the notion of regulatory objectivity can be tested, extended, revised, or superseded by more appropriate notions. They insist on the need to examine more closely clinical-therapeutic (and not just clinical-research) activities, and to pay more attention to the activities of regulatory agencies such as the US Food and Drug Administration and to standard-setting organizations. They call attention to the professional and organizational activities surrounding the mobilization of conventions for regulating clinical practices. Finally, they provide material that can help us to think about how analytical notions such as regulatory objectivity may or may not inform interventionist research projects.

The Risks of Medical Innovation : Risk Perception and Assessment in Historical Context

Preface. Risk and Medical Innovation: A Historical Perspective. To Assess and to Improve: Practitioners? Approaches to Doubts Linked with Medical Innovations 1720-1920. Anaesthesia and the Evaluation of Surgical Risk in Mid-Nineteenth Century Britain. Redemption, Danger, and Risk: The History of Anti-Bacterial Chemotherapy and the Transformation of Tuberculin. As Safe as Milk or Sugar Water?: Perceptions of Risks and Benefits of the BCG Vaccine in the 1920s and 1930s in France and Germany. From Danger to Risk: The Perception and Regulation of X-Rays in Switzerland 1896-1970. The Population as Patient: Alice Stewart and the Controversy over Low-Level Radiation in the 1950s. To Treat or Not to Treat: Drug Research and the Changing Nature of Essential Hypertension. Hormones at Risk: Cancer and the Medical Uses of Industrially-Produced. Sex Steroids in Germany, 1930-1960. Assessment and Medical Authority in Operative Fracture Care in the 1960 and 1970s. Assessing the Risk and Safety of the Pill: Maternal Mortality and the Pill. Addressing Uncertainties: The Conceptualisation of Brain Death in Switzerland 1960-2000. Risk on Trial. The Interaction of Innovation and Risk in Cancer Clinical Trials. BioRisk: Interleukin-2 from Laboratory to Market in the United States and Germany. The Redemption of Thalidomide: Standardizing the Risk of Birth Defects

The Art and Science of Surgery: Innovation and Concepts of Medical Practice in Operative Fracture Care, 1960s–1970s:

In this article, I am using the example of the introduction of osteosynthesis into surgical routine practice to analyze the use of the notions of art and science in medical innovation. The examination of the renegotiations of power and responsibility associated with the introduction of this new technique shows that proponents and critics actively linked their arguments to more fundamental epistemological and social issues. The proponents claimed to manage the uncertainties of innovation through making surgery more scientific, drawing on the ideals of control, rationality, objectivity, and predictability. The critics mobilized another discursive pattern. They considered surgery an art and emphasized the individuality, contingency, and situatedness of medical practice. I investigate the discursive function of these argumentative patterns and how they played out in the concrete example of this surgical technique.

Asepsis and bacteriology : a realignment of surgery and laboratory science

This paper examines the origins of aseptic surgery in the German-speaking countries. It interprets asepsis as the outcome of a mutual realignment of surgery and laboratory science. In that process, phenomena of surgical reality were being modelled and simplified in the bacteriological laboratory so that they could be subjected to control by the researcher’s hands and eyes. Once control was achieved, it was being extended to surgical practice by recreating the relevant features of the controlled laboratory environment in the surgical work place. This strategy can be seen in the adoption of Robert Koch’s bacteriology by German-speaking surgeons, and the resulting technical changes of surgery, leading to a set of beliefs and practices, which eventually came to be called ‘asepsis’.

Surgery, science and modernity : Operating rooms and laboratories as spaces of control

In this paper, I take a new perspective on the history of operating rooms as the key site of modern surgical practices. For this purpose, I draw the parallel with the history of another space, the laboratory, as a backdrop, thus linking up two fields of scholarship that have remained mostly separate until now. I will re-examine the literatures of both fields and take them further by drawing on approaches from history, sociology, and science and technology studies. Adding a few exemplary sources, I analyse the history of operating settings and discuss what they have in common with laboratories and how both spaces influenced each other over time. Taking the detour through the laboratory will make certain features in the development of operating rooms better visible. Above all, it will help to characterize the modern operating room as a space of control, very much like the modern laboratory. This interpretation goes beyond the usual explanation of operating room design as shaped by the requirements of asepsis. Asepsis can be characterized as just one aspect of the broader purpose of control. The purpose of control, in turn, is a general phenomenon in the development of modern societies. As pointed out in the conclusion, an analysis along these lines might open up new ways of examining the history of modern surgery as one element of a more general development in modern, industrialized societies. Like any analysis of architectural design, the history of operating rooms raises the issue of how to deal with the dimension of function versus meaning. In my line of argument I will, in the first instance, look at how changes in the spaces used for surgery were part of surgeons’ strategy to achieve more control over their working conditions and thus over the bodies they sought to manipulate. The focus will be on the concrete, practical increase in technical power. However, I will also discuss the symbolic dimension of spatial organization and design and suggest a way to deal with the relationship between the practical and the symbolic in interpreting medical spaces more generally.

Design for Control: Surgery, Science, and Space at the Royal Victoria Hospital, Montreal, 1893–1956

In this paper we explore the relationship of modern architecture and modern surgery in the twentieth century. Our central argument is that environments designed for surgery in the modern hospital became more like laboratories at the end of a remarkable metamorphosis, which we explain through three distinct types of spaces in a particularly significant case study, the Royal Victoria Hospital (RVH) in Montreal, Quebec.

“One and the Same the World Over”: The International Culture of Surgical Exchange in an Age of Globalization, 1870–1914

ABSTRACT:This paper examines the international exchange in surgery in the decades before World War I, a period of growing globalization in communication and transport. Focusing on Europe and North America, it looks first at the various means of exchange, especially surgical travel and the culture emerging around it and follows specific directions of exchange, from France and Britain, first to the German-speaking countries and finally to North America. Subsequently, the account turns to international organizations as an important means of exchange in this time period. The International Society of Surgery, in particular, provided a forum for a vivid internationalist discourse, which, however, stood in tension with simultaneous nationalist tendencies leading up to World War I. The paper finally discusses how the international exchange and communication at the time can be seen as an instance of modern surgeons claiming—and simultaneously trying to create—the global universality of surgical knowledge and practices, making sure that surgery is the same the world over.

Changing disease identities: cretinism, politics and surgery (1844-1892).

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'The Days of Brilliancy are Past': Skill, Styles and the Changing Rules of Surgical Performance, ca. 1820-1920.

This paper examines how, over the course of the nineteenth and early twentieth centuries, the appreciation of skill in surgery shifted in characteristic ways. Skill is a problematic category in surgery. Its evaluation is embedded into wider cultural expectations and evaluations, which changed over time. The paper examines the discussions about surgical skill in a variety of contexts: the highly competitive environment of celebrity practitioners in the amphitheatres of early nineteenth-century Britain; the science-oriented, technocratic German-language university hospitals later in the century; and the elitist surgeons of late nineteenth and early twentieth-century United States with their concerns about distancing themselves from commercialism and cheap showmanship. For analysing the interaction of surgical practices with their various contexts the paper makes use of the concept of ‘performance’ and examines how the rules of surgical performance varied according to the prevailing technical, social, and moral conditions. Over the course of the century, surgical performance looked more and more recognisably modern, increasingly following the ideals of replicability, universality and standardisation. The changing ideals of surgical skill are a crucial element of the complex history of the emergence of modern surgery, but also an illuminating example of the history of skill in modern medicine.

A “Life Dedicated to True Science”: Eduard Pflüger and the Nobel Prize for Physiology or Medicine

The Nobel Prize Archive for Physiology or Medicine in Stockholm has recently gained scholarly attention among historians [8, 12, 22], but it has not yet been sufficiently examined by historians of physiology [13]. Studies of Nobel Prize nominations of renowned physiologists and reports by the Nobel Committee can help reconstructing many of the important developments in the field of physiology over the last century. Drawing on documents from the Nobel Prize Archive, we examine why contemporary scientists argued that the German physiologist Eduard Friedrich Wilhelm Pflüger (1829–1910) was “the person who [had] made the most important discovery within the domain of physiology or medicine” (quote from Alfred Nobel’s will of 1895 [15]), look at his strongest Nobel Prize competitors, and discuss the reasons of the Nobel Committee for not awarding him. Eduard Pflüger founded the Archiv für die gesammte Physiologie des Menschen und der Thiere in 1868. The first issue included papers by senior and junior physiologists such as Franciscus Donders (1818–1889) [9], Hermann von Helmholtz (1821–1894) [14], Julius Bernstein (1839–1917) [2], and Nathan Zuntz (1847–1920) [27]. The new periodical acquired an immediate strong reputation in Europe. At the turn of the century, the journal gained international fame after the publication of groundbreaking research in the field of electrophysiology, for example, Ernest Overton’s (1865–1933) major contributions on the structure and function of cell membranes [23] and Julius Bernstein’s physical explanation of the resting membrane potential [3]. Today, Pflüger is a household name among physiologists because of the journal, which even after name discussions [19, 20] still is abbreviated Pflugers Arch., but also for Pflüger’s Law of polar excitation (Pflüger’sche Zuckungsgesetze, in fact three laws), which refers to the correlation between electrical stimulation and muscular contraction. These laws were described by Pflüger in 1859 [25]. Prior to that publication, Pflüger discussed them in a correspondence with Helmholtz [24]. Pflüger’s biography is of particular interest to physiologists since it exemplifies the development from the time before physiology existed as an independent speciality until it had become a cornerstone of medical research and education—a function that Pflüger himself has encapsulated in his adage that a “... physician without physiological knowledge is like a watchmaker who is supposed to correct the abnormal action of a clockwork, but is ignorant of the normal operating conditions of the machine he is called to repair.” [29]. At the end of his life, Pflüger was able to look back on a long and dynamic career: starting with his first experiments as assistant to Johannes Müller (1801–1858) and student of Emil du Bois-Reymond (1818–1896) in the early 1850s, up to his controversial ideas on the origin of diabetes 50 years later [29]. Pflüger, born in the small town Hanau near Frankfurt am Main on 7 June 1829, earned his MD in 1855. In 1859, barely 30 years old, he became chair of physiology at the Rheinische Friedrich-Wilhelms-University of Bonn. A few months later, Pflüger gained international recognition after his investigations on the effects of electricity on irritability and the frog nerves’ response to stimuli [26]. Over the years, Pflüger received many scientific prizes and he became member of several foreign scientific societies, but he was never awarded the Nobel Prize for Physiology or Medicine, even though he was one of the most nominated physiologists for the prize in the first decade of the twentieth century. From 1902 to 1910, Pflüger was proposed by at least 40 professors of medicine. N. Hansson (*) Department of Medical Ethics and History of Medicine, University Medical Center, Humboldtallee 36, 37073 Göttingen, Germany e-mail: nhansso@gwdg.de