Tools in Action: The Auscultation of Medical Practices from Past and Present

Review of: Jens Lachmund, Der abgehorte Koerper, Zur historischen Soziologie der medizinischen Untersuchung, Westdeutscher Verlag, 1997; and Marc Berg, Rationalizing Medical Work, Decision-Support Techniques and Medical Practices, MIT Press, 1997.

The medicine of western cultures is technomedicine. Both practitioners and advocates of technomedicine, as well as its adversaries and critics stress the pre-eminent role of technology in medicine. The use of instruments and technical devices is probably the distinctive characteristic of this form of medicine. From microscopic needles and scissors to large-scale scanners and visualisation devices, from operating robots to computerised filing systems, hardly any encounter with medicine nowadays occurs in a technology-free space.

Techniques and instruments do not only expand medicine into new dimensions of the human body, providing ever more diagnostic and therapeutic options, but they are at the heart of medicine. Modern medicine is enmeshed with technology. Nevertheless, the roles of technology in medicine and the modes of its functioning have only recently become an object of investigation. Particularly, visualisation techniques have been studied as representational techniques. The books under review here pursue another strategy. They observe tools in action.

How exactly does technology interfere with medicine? How do technical devices come to be nested in medical practice? To answer these and similar questions, both authors follow particular devices on their way from the construction site through initial attempts of use, back into the hands of designers, to the hospitals, through several countries and into further translations. On the way back and forth, the tool or instrument is constantly being reconstructed, reshaped, and re-conceptualised, but the practice of medicine to which it becomes increasingly essential is also moulded during this process. Furthermore, scientific theories and concepts have to be adjusted to the output produced by the new devices. The stepwise unfolding and emergence of the applicability and usability of a tool, the consequent adjustment of the sciences and practices of medicine result from ongoing negotiation and networking, with, in turn, re-entry effects within medicine as a social institution. So there is an awful lot to see when you follow an instrument around; even more might remain invisible, and become approachable only through even more thorough investigative strategies.

The first book investigates one of the starting points of technomedicine: the introduction of the stethoscope into medical practice. Because it founded a completely new version of physical examination, it led to a revolution of the science and practice of medicine. The second looks at the relative failure of the latest advance in technomedicine, the attempts to delegate the organisation of technomedicine in a recursive loop to second order technologies which were to organise and select the use of diagnostics and therapeutics. These so-called decision-support techniques range from simple protocols to sophisticated computer programmes and expert systems dealing with the immense amount of data and complexity in medical decision making. Techniques of this sort are widespread, but the selection and control of medical actions still remains by and large in the hands of the doctors.

Medicine has always been a technology of knowledge, not just in Foucault’s reading, but also in Plato’s analysis. However, in his The Birth of the Clinic, Foucault has shown how this technology of knowledge took a turn around 1800, preparing the ground for new principles, typical of medicine still today. Although the predominant role of instruments and machines in modern medicine can be traced back to exactly this break in the history of medicine, Foucault has written surprisingly little about the role of instruments and techniques in medicine before and after.

Modern medicine is in a sense a technology-based technology of knowledge, as Jens Lachmund now has convincingly shown. From this point of view, he has written the sequel to The Birth of the Clinic, not only delivering the missing bits of the story and addressing questions open since 1972, but also demonstrating how the introduction of an instrument reorganised the practice of medicine and thereby medicine itself as a form of scientific knowledge. The new instrument of the stethoscope, the focus of his study, and the new ways of diagnosing diseases it made possible, cannot simply be understood as an intrinsic development of medicine, gradually emerging as a science towards more objectivity and higher precision. Lachmund’s aim is to show how the cultural understanding of diseases, the concepts of objectivity and medical expertise were reconstructed along the way, and how the new form of physical examination together with the new pathological anatomy formed the interior space of the body into an object of medical knowledge, accessible only through the instrument by the expert-physician.

Such a historical investigation of the sociology of scientific knowledge and its cultural reconstruction depends on the richness of the source material at one’s disposal, since it requires much more than simply tracing out the spreading of this technique. Whereas Marc Berg, himself trained in medicine, could literally follow his tools around in participant observations, Jens Lachmund had to reconstruct a delicate network from the past, tracking down the debates surrounding the introduction of this instrument instead of the published successes with it. To gain access to these topics, Lachmund concentrates on textbook and handbook material from the 19th century, in a sense documenting the ‘state of the art’.

However, he combines and contrasts this with unpublished material, such as letters and autobiographies from the same period, reflecting encounters with the medicine of those days in private conversation. It is this well chosen material that allows him to reconstruct the cultural shifts in which this epistemological break in the history of medicine was embedded and in which it participated.

Lachmund begins by reconstructing the traditional medicine as a discursive practice, located around the bed of the ill. The physician came into the house of his patient, talked with the patient and his family, and developed in this discourse his statement, qualifying the disease, giving a prognosis and recommending a treatment. Diseases were the hybrids of the medical literature end terminology on the one hand and the cultural product of the discourse at the bedside on the other hand but there was hardly any direct physical contact between the physician and the patient, and no physical examination proper. Comparatively few members of the society could afford such medical treatment, hence the physician and the patient were on a social par, if indeed the physician was not inferior.

The situation had changed dramatically, when Laennec published his first paper in 1819 on the form and use of the stethoscope - a small device connecting the ear of the physician with the body of the patient. Since Ackerknecht’s seminal study from 1968 on the Paris hospital, the emerging form of medicine has been labelled after its location, the medicine of the hospital. But it was more then just a change of the site of medical practice. First and foremost, the social setting of this new form of medicine differed radically from its predecessor. The new hospitals mainly served patients from the lower classes, giving the physicians an unforeseen advantage of social prestige, subordinating patients to their command and leaving the medical discourse to the physician-experts. The counterpart to this shift in social organisation was a reorganisation of the science of medicine, a new topography of diseases as produced in the morgue by way of post-mortems. Foucault has shown how the opening of the body related to a new organisation of medical knowledge, dominated by spatial relations and visual representations.

It is here that Lachmund takes over. According to his analysis, it was the local setting of medical practice at the hospital in Paris that enabled Laennec to employ his instrument successfully. The contingent constellation was the precondition for the acceptance of Laennec’s new form of physical examination. Only here could the culturally fixed rules for the interactions between physician and patient be violated by the use of the stethoscope. And only here, in the context of a topography of diseases in the body, did the production of new signs, by way of a physical examination, make sense. Here these signs could be related to the location of a disease as revealed by the autopsy. With the stethoscope, the sound could be related to a seen alteration of the body, and united to a new classification of diseases. In the situation of the Paris hospital, the stethoscope linked pathological anatomy with the clinic.

Thereby it mediated the production of the new type of hospital medicine. Nobody believes in technological determinism any more, and neither does Lachmund, but he shows how the technical side of an artefact structures the possibilities of its employment. In the case of the stethoscope, the required silence, for example, and the repetition of certain commands, shifted the control of the interaction from the patient to the physician. Yet it also forced the physicians into a specific training and to an extension of their sensibility. The invention of the instrument had to be implemented via the construction of a medical sense of hearing. With this new sense of hearing, ever more clinical signs poured out, following Laennec’s initial observations, which were highly debated among the experts and discounted by the adversaries of the whole new technique. The very productivity of the technique made strategies of stabilisation and standardisation necessary, i.e., a reduction to reproducible signs.

But reproducibility was as much a question of objectivity as of ability and skill. Dependent on local experience, the negotiations on the use of the instruments, on the criteria for the interpretation of the data and on the classification of the signs developed in different directions, producing different systems of medical practice, different worlds of medical objectivity, different realities of medical practice. Nature, by way of the sounds produced in the body, had scant influence on the use of such sounds as data for medical purposes, one can conclude Lachmund’s narrative.

When a case study puts so much weight upon local contingencies in explaining long term developments, this must be validated in a comparative analysis. Lachmund finds his contrasting examples along the route his instrument travelled through Europe. In the attempts to transfer the new technology of hearing and the physical examination to Vienna and Germany, again, we find the local settings constraining its use and thereby shaping a new form of medicine. But against these remaining local styles and national differences, we also see a form of medicine emerging which is still part of medical practice today. The local cultural constructions of medical practice become justified as scientifically valid in this very process.

And it is here, where, in my view, his study pays off most. Lachmund sketches the trajectory of the stethoscope, thereby revealing the history of medicine as scientific practice. Unfortunately, the very instrument of this process, the stethoscope, is treated more like a black box most of the time. I was somewhat disappointed by the brief chapter on its design and technical development which seems largely disconnected from the rest of Lachmund’s narrative.

Lachmund develops his story with little regard to mine fields in the historiography of medicine. He does not touch the tricky question of the relations between medicine and Romanticism, for example, or the rise of the physiological laboratory. Since his aim is particularly the reconstruction of the cultural production of the scientific knowledge of medicine, his arguments, without a more detailed picture of the theories in the medicine of the time, remain somewhat vague, but overall, it is a fresh and stimulating approach to the history of medicine which also proves that ethnographic methods can be profitably employed in a historical analysis.

Marc Berg takes up the thread almost a hundred years later, analysing the roles and functioning, of what he calls ‘decision support techniques’, tools that promise to guide medical personnel scientifically through their work. He looks at three different sorts of tools: decision-support systems, which analyse statistically data from a single case with regard to disease classifications; protocols, which steer the caretaker stepwise through a specific procedure; and finally expert systems, which deliver statistically the best management to an individual case. In some ways, these tools can be arranged in a temporal order, with the decision-analysis coming first, being replaced by expert systems, and the protocols coming in from another side, but abounding today. All these tools have been introduced into medicine at a certain stage to improve its rationality. Therefore, what is at stake is the rationality of medical practice and thereby of medicine itself. The exponential growth of medical knowledge after World War II, which increased enormously the complexity of nearly all medical procedures, but also the increasing pressure to justify medical practice rationally in the new scientific world-view of those days, pushed the medical system to overcome the traditional setting of medical practice under the framework of medicine as an art and applied science. In the historical part, Berg’s analysis offers a fine periodisation of post-war medicine in terms of fashionable concepts of rationality, which gradually supersede earlier conceptualisations of medicine as based upon art and individual expertise.

He looks at this permanent reshaping of medicine, propagated under the banner of its promised rationalisation, from three different perspectives: by reviewing the medical literature, by giving voice to the system builders, and, finally, by participating in medical practice and focusing on medical personnel. In all three perspectives, Berg reveals perplexing ambiguities in the ‘process of rationalisation’. The rationalisation of medicine as a ‘science’ meant standardising medical practice in both its style and degree of complexity to make it digestible by computer techniques. Designing a tool meant permanent compromising between the details of the data and the logic of its processing. Setting a tool to work meant disciplining a practice to the abilities of a machine. Furthermore, the disciplining of a local practice becomes entangled in the localisation of the tool, where tool and practice finally converge. The interaction with these tools was simultaneously an interaction with the medical data and the criteria for their interpretation. There was no true representation of a condition through the tool, but instead an endless tinkering with its functioning. The decision-support technologies did not become the central decision-maker. Instead they participated as an additional active element in the network. For Berg, the via regia to the underlying dynamics is obviously prepared by the work of Latour and Law, from whom he also adopts their jargon.

Instead of a ‘rationalisation’ of medical practice (which one may or may not wish), Berg sees divergent rationalities at all levels and places of this process:

Instead of the transparent, optimal, unified, Clinical Rationality hoped for, we end up with opaque, impure, additional rationalities. Instead of imposing order where there was disorder, an order is achieved that incorporates the very messiness it started out to curtail. (p. 116)

Only by the detailed reconstruction of the local effects of a tool at work, by the unfolding of its specific trajectory in its local setting, does one get to an understanding of the dynamics of ‘rationalising medicine’. Localisation occurs in Berg’s study on the methodological level as well as on the systematic. One of the characteristics of his ‘diverging rationalities’ is their localisation in space, scope, and rationale, all of which serve to get a system to work by setting its limits. Berg also shows how ‘soft’ and ‘hard’ data differ mainly in the amount of discipline imposed upon the practice producing them, rather than reflecting any qualities of objectivity.

The book displays many fascinating facets and details, especially from the rich material of his interviews and participant observations. For example, we learn that there is no other way to evaluate an expert system in medicine than the good old Turing Test. Experts ultimately could not decide whether a treatment was suggested by the system or a colleague. But although the system passed the test, it nonetheless was never properly employed, because the doctors disliked the way they had to feed in the data. In another situation, the decision-analysis only ‘worked’ when it was instructed in an obviously false way, since it behaved as a trouble-maker. The implicit logic of medical practice on a ward was frequently in conflict with the procedure suggested by the decision-support systems. Situations of this type were solved by foreseeing the outcome of the machine and guiding it in a different direction through the alteration of data. These are not simply entertaining stories from everyday life; they tell us of the very complexity of daily life. Just before the final, summarising chapter, Berg develops an idea I would like to know more about: the disappearance of the notion of a cognitive decision in medical practice. Decisions were always enmeshed in the treatment of a patient, crystallising as decisive points only in post hoc attributions. Decisions exist as points to be referred to in the accounts of these processes, but cannot be anticipated, planned or organised.

I was nonetheless disturbed upon finishing the book by the blunt and general conclusions Berg draws from his own work. As one can see in the quotation above, his argument works only on the condition that one accept in the first place the simple dichotomies by means of which Berg organises his field of study, and between which he finally wants to situate himself. I find it strange that someone who constantly argues for heterogeneity, varieties and complexity applies such a straightforward strategy in his own argument, thereby ignoring and pushing aside the very details he so carefully harvested along the way. ‘Clinical Rationality’ with capitals simply does and did not exist, even before Berg’s study. Once being irritated about such a generalisation constraint in Berg’s work, one wonders whether the three examples of decision-support techniques should really be studied as examples of a common type. Especially protocols probably share at least as many characteristics with typical documentation and examination sheets as with expert systems. So why does Berg level those differences?

author’s address:

borck@mailmac.mpiwg-berlin.mpg.de