‘A river that is cutting its own bed’: the serology of syphilis between laboratory,society and the law

This paper focuses on the role of regulation in the shaping new scientific facts. Fleck chose to study the origins of a diagnostic test for a disease seen as a major public health problem, that is, a ‘scientific fact’ that had a direct and immediate influence outside the closed universe of fundamental scientific research. In 1935, when Fleck wrote his book, Genesis and development of a scientific fact, he believed that the tumultuous early history of the Wassermann reaction had come to an end, and that this reaction was successfully stabilized through the standardization of laboratory practices and thanks to the rise of a specific professional segment—the serologists. He could not have predicted that in the 15 years that followed the publication of his book, regulatory measures—barely metioned in his historical narrative—would play a key role in the destabilization of the original meaning of this reaction. The introduction of mass screening for syphilis—mainly via legislation that introduced obligatory premarital tests and promoted the testing of pregnant women—weakened in fine the link between Wassermann serology and infection by the etiological agent of syphilis, the bacterium Treponema pallidum. Fleck elected to study the Wassermann reaction because of its novelty, its complexity, and because it became the focus of a controversy regarding its origins. However, the Wassermann reaction was also one the first examples of a medical technology regulated by the state and incorporated into legal dispositions. It may therefore be seen as an exemplary case of the close intertwining of scientific investigations, their practical applications and regulatory practices.     

Prior consent as a liberal theory of health care rationing: commments of Savulescu's constructive critique

[In his review essay in this issue of Bioethics,] Julian Savulescu lucidly summarizes and assesses each essay in Strong Medicine. I would like to clarify a few important general points about prior consent as a conceptual framework for the ethical rationing of health care, correct several specific misreadings, and defend my basic claim despite some acknowledged problems.     

Consequentialism, reasons, value and justice

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris rejects welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources.     

Mental health services--the user's view.

The needs of people with serious mental illnesses have dominated much of the debate on reforming community care. In this article Peter Campbell, who has used mental health services many times in the past, explains how the reforms could affect people like him. He welcomes the thinking behind the changes, particularly the idea that people who use community care should take part in planning services, but he warns that implementing the new philosophy might prove very difficult. Mr Campbell is secretary of a voluntary organisation for users of mental health services called Survivors Speak Out. The views he expresses here are his own, and do not necessarily reflect those of Survivors Speak Out.     

Linnaeus's natural and artificial arrangements of plants

Linnaeus's artificial and natural arrangements of plants are examined using a Spearman rank coefficient (which is explained) on his presentations of his own and others' arrangements in the Classes plantarum and elsewhere. There is little alteration in his successive artificial arrangements. In contrast, between 1751 and 1764 his natural arrangements changed considerably, partly in the sequences of genera within orders but mostly by rearrangement of the orders. Comparison with Cesalpino's and Ray's natural arrangements, using the longest-recognized natural groups as signposts, suggests that Linnaeus in his latest natural arrangement (1764) approximated more closely to Ray's. Examination of Linnaeus's successive treatments of certain groups (palms, Zingiberaceae, Hydrocharis-Stratiotes-Vallisneria) and of Giseke's exposition of Linnaeus's lectures on natural groups (1792) shows that Linnaeus was much influenced by habitus and vegetative characters as well as those of the fructification. He recognized orders consisting of a chain of genera linked successively by overall affinity and without any single diagnostic character. Where possible, he preferred characters of the fructification and his ‘secret’ consulting of the habitus is explained as secondary to such characters. It is suggested that in his latest arrangement he approximated more to a scala naturae, as he probably did in zoology about the same time. Within his artificial arrangements Linnaeus kept to sequences of genera as natural as possible. He realized that some groups in his natural arrangements were still artificial, and his aphorism that all genera and species are natural, classes and orders part natural and part artificial, refers to his and others' practice until the natural system could be completed. It is not a statement of the essential natures of these ranks. Linnaeus's distinction in practice between natural and artificial arrangements was less clear-cut than Sachs believed. Linnaeus's rejection of the ancient tree/herb division was empirical, not a reasoned repudiation of an a priori grouping. The tree/herb division could be upheld in his day as obviously natural, not merely accepted on authority.     

The specificity of medical facts: the case of diabetology

The fact that Ludwik Fleck drew his inspiration from medicine has been largely overlooked, with the exception of a few scholars. Although Fleck considered his ideas applicable to all sciences, he always insisted on the specificity of medicine. To illustrate the usefulness of Fleck’s concepts for the history of medicine, three main ideas developed by Fleck are applied to the historical study of diabetes mellitus (DM): first, that different and often divergent pictures of disease coexist within a given culture; second, that scientific ideas circulate between ‘esoteric’ and ‘exoteric’ circles; and third, that scientific concepts are often incommensurable. The author also suggests that Fleck’s epistemology, like other scholars’, is loaded with ethical and political consequences. However, the link between an ‘open’ epistemology and political or ethical questions is more explicit in Georges Canguilhem’s pioneering work on the normal and the pathological (1943). Indeed, Canguilhem and Fleck’s conceptions of disease have much in common, so that we can use Canguilhem’s work to bring out the hidden ethical and political issues in Fleck’s work.     

Personalia and the current health crisis.

Recent changes in the Russian government introduced by Boris Yeltsin include the appointment of Eduard Nechaev as health minister at the beginning of this year. The appointment received little publicity in the West, although his predecessor was sacked after only one year for failing to make any effort to improve health care. The challenges facing the new minister are enormous. Not only does he have to introduce a new medical insurance system but he has to tackle the problems of falling population, rising childhood illness linked to poor diet, and the spread of polio and diphtheria. It remains to be seen whether his experience in the military medical service has equipped him for the job.     

Medicine, public health, and the ethics of rationing.

Physicians, like all citizens, have communal and private identities, each attending various associated roles and fulfilling diverse obligations. In light of these dual personae, we seek a moral philosophy which encompasses the responsibility for providing care to the patient and at the same time acknowledges the physician's role of arbiter of distributed care. In the traditional doctor/patient relationship, rationing, the admission that health resources are limited and must be distributed equitably by universally accepted criteria, is essentially ignored. When the physician assumes a population-based system of ethics to optimize care for all patients within a group, rationing is embraced as the realistic admission that any social action resides within boundaries--in this case health care resources--and that such restraints have economic consequences that present ethical choices. A common ground to accommodate these dual allegiances is offered by communitarian philosophy, whose outline and applicability is presented here as an alternative to the apparent moral opposition of optimized individual care and the requirement of community-wide distribution of limited health resources.     

From the laboratory to the patient and back--an interview with Marc Mareel. Interview by Marc E. Bracke

The career of Marc Mareel is a synthesis of scientific research and clinical activity. During his medical studies, he already made his first enthusiastic steps in research via experimental work on avian developmental biology. Later, during his training as a radiotherapist, he founded his own laboratory for experimental cancer research. There he built up his international reputation as a pioneer in invasion research. Although invasion is the hallmark of tumor malignancy, he also kept an open mind about invasion in non-cancer conditions, such as in placental behavior, developmental biology, immunology and parasitology. His contribution to our understanding of invasion mechanisms has been both technical and conceptual. A number of assays have been developed in his lab, such as the embryonic chick heart and collagen gel invasion models, that have been (and still are) useful for many other research teams. He also contributed to the discovery of a number of key elements in the process of invasion, such as the stromal influence (including its extracellular matrix) and the cadherin family of cell-cell adhesion molecules. Concerning metastasis formation, he developed the original concept that a number of interacting eco-systems are implicated, such as the primary tumor, regional lymph nodes, the bone marrow and the (pre)metastatic niches in distant organs. Since his retirement, Marc Mareel has continued to integrate clinical practice with research creativity. He favours the idea of translational research bringing the results of laboratory findings to medical applications, and exploiting the feedback to the laboratory. The team in the Laboratory of Experimental Cancer Research at Ghent University currently consists of about 25 collaborators, who continue to appreciate his inspiring ideas and suggestions.     

Fleck and the social constitution of scientific objectivity

Ludwik Fleck’s theory of thought-styles has been hailed as a pioneer of constructivist science studies and sociology of scientific knowledge. But this consensus ignores an important feature of Fleck’s epistemology. At the core of his account is the ideal of ‘objective truth, clarity, and accuracy’. I begin with Fleck’s account of modern natural science, locating the ideal of scientific objectivity within his general social epistemology. I then draw on Fleck’s view of scientific objectivity to improve upon reflexive accounts of the origin and development of the theory of thought-styles, and reply to objections that Fleck’s epistemological stance is self-undermining or inconsistent. Explicating the role of scientific objectivity in Fleck’s epistemology reveals his view to be an internally consistent alternative to recent social accounts of scientific objectivity by Harding, Daston and Galison. I use these contrasts to indicate the strengths and weaknesses of Fleck’s innovative social epistemology, and propose modifications to address the latter. The result is a renewed version of Fleck’s social epistemology, which reconciles commitment to scientific objectivity with integrated sociology, history and philosophy of science.     

A harmony of illusions: clinical and experimental testing of Robert Koch’s tuberculin 1890–1900

One of Ludwik Fleck’s ideas about the development of scientific knowledge is that—once a system of interpretation is in place—the process that follows can be characterised as one of inertia: any new evidence comes under a strong pressure to be incorporated into the established frame. This can result in what Fleck called a harmony of illusions (Harmonie der Täuschungen) when contradictory evidence becomes almost invisible or is incorporated into the established frame only by huge efforts.The paper analyses early explanations of the tuberculin reaction as a case study of Fleck’s argument. For Robert Koch, who had presented tuberculin in 1890, the compound was supposed to be a diagnostic tool and a cure for tuberculosis. His conception of its effect was rather peculiar, but strictly in line with ideas on the pathogenesis of infectious diseases he had developed much earlier. After tuberculin was released in late 1890, whether Koch’s conception was convincing depended on the place that a given observer had in the medical world in late-nineteenth-century Germany. Inside Koch’s group, the status of the tuberculin reaction remained stable and tuberculin retained its value as a diagnostic and curative tool. On the other hand, observers from outside that thought collective, and in particular from clinical medicine, soon pointed to flaws in its conception. These critics developed a rather different picture of tuberculin as a mysterious and dangerous drug. No reconciliation followed and what we find instead in German medicine around the year 1900 is the presence of rather contradictory concepts and practices surrounding Koch’s wonder cure.     

The rationing agenda in the NHS. Rationing Agenda Group.

The Rationing Agenda Group has been founded to deepen the British debate on rationing health care. It believes that rationing in health care is inevitable and that the public must be involved in the debate about issues relating to rationing. The group comprises people from all parts of health care, none of whom represent either their group or their institutions. RAG has begun by producing this document, which attempts to set an agenda of all the issues that need to be considered when debating the rationing of health care. We hope for responses to the document. The next stage will be to incorporate the responses into the agenda. Then RAG will divide the agenda into manageable chunks and commission expert, detailed commentaries. From this material a final paper will be published and used to prompt public debate. This stage should be reached early in 1997. While these papers are being prepared RAG is developing ways to involve the public in the debate and evaluate the whole process. We present as neutrally as possible all the issues related to rationing and priority setting in the NHS. We focus on the NHS for two reasons. Firstly, for those of us resident in the United Kingdom the NHS is the health care system with which we are most familiar and most concerned. Secondly, focusing on one system alone allows more coherent analysis than would be possible if issues in other systems were included as well. Our concern is with the delivery of health care, not its finance, though we discuss the possible effects of changing the financing system of the NHS. Finally, though our position is neutral, we hold two substantive views--namely, that rationing is unavoidable and that there should be more explicit debate about the principles and issues concerned. We consider the issues under four headings: preliminaries, ethics, democracy, and empirical questions. Preliminaries deal with the semantics of rationing, whether rationing is necessary, and with the range of services to which rationing relates. Under ethics and democracy are the substantive issues of principle and theory. The final section deals with empirical questions and those relating to the practicality of various strategies.     

Haeckel,un darwinien allemand ?

German biologist Ernst Haeckel (1834–1919) is often considered the most renowned Darwinian in his country since, as early as 1862, he declared that he accepted the conclusions Darwin had reached three years before in On the Origin of Species, and afterwards, he continuously proclaimed himself a supporter of the English naturalist and championed the evolutionary theory. Nevertheless, if we examine carefully his books, in particular his General Morphology (1866), we can see that he carries on a tradition very far from Darwin's thoughts. In spite of his acceptance of the idea of natural selection, that he establishes as an argument for materialism, he adopts, indeed, a conception of evolution that is, in some respects, rather close to Lamarck's views. He is, thus, a good example of the ambiguities of the reception of Darwinism in Germany in the second part of the 19th century. To cite this article: S. Schmitt, C. R. Biologies 332 (2009).     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

Robert Chambers and Thomas Henry Huxley, Science Correspondents: The Popularization and Dissemination of Nineteenth Century Natural Science

Robert Chambers and Thomas Henry Huxley helped popularize science by writing for general interest publications when science was becoming increasingly professionalized. A non-professional, Chambers used his family-owned Chambers' Edinburgh Journal to report on scientific discoveries, giving his audience access to ideas that were only available to scientists who regularly attended professional meetings or read published transactions of such forums. He had no formal training in the sciences and little interest in advancing the professional status of scientists; his course of action was determined by his disability and interest in scientific phenomena. His skillful reporting enabled readers to learn how the ideas that flowed from scientific innovation affected their lives, and his series of article in the Journal presenting his rudimentary ideas on evolution, served as a prelude to his important popular work, Vestiges of the Natural History of Creation. Huxley, an example of the new professional class of scientists, defended science and evolution from attacks by religious spokesmen and other opponents of evolution, informing the British public about science through his lectures and articles in such publications as Nineteenth Century. He understood that by popularizing scientific information, he could effectively challenge the old Tory establishment -- with its orthodox religious and political views -- and promote the ideas of the new class of professional scientists. In attempting to transform British society, he frequently came in conflict with theologians and others on issues in which science and religion seemed to contradict each other but refused to discuss matters of science with non-professionals like Chambers, whose popular writing struck a more resonant chord with working class readers. This revised version was published online in July 2006 with corrections to the Cover Date.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

From Darkness to Light

Not so long ago I happened to treat a Jewish eighth-grade gymnasium student brought to Petrograd from a province. It was fall and the following spring he was to take his qualifying examinations. The young man, who belonged to a prosperous family, had brilliant abilities and graduated from each class with excellent grades—what would you think his illness was? He suffered—in his own words—from the throes of creative writing. Days and nights he poured over a notebook with his compositions in search of the best form to express his thoughts. Only after applying incredible efforts could one tear him away from his note-books and send him to bed at five or six o'clock in the morning, and this happened on a daily basis. With each day his mental health grew worse. It was clear that the young man undermined his health by overstudying, and that he had reached the point where he needed to worry about his health, not his studies, because a serious mental illness was descending upon him. The young man was well liked by everyone in his high-school. The teachers considered him the best student, and having learned about his illness, they promised to petition to grant him the right to graduate from school without the final examination and with a certificate of excellent. But none of that helped. The young man could not relax, spending days and nights over his compositions and constantly tormenting himself with his "throes of creative writing."     

Stephen Hales: neglected respiratory physiologist

Stephen Hales was an eminent early 18th century scientist and minister of the parish of Teddington near London. He is well known for his early work on blood pressure. However, he made many contributions to respiratory physiology. He clarified the nature of the respiratory gases, distinguishing between their free (gaseous) and fixed (chemically combined) forms, demonstrated that rebreathing from a closed circuit could be extended if suitable gas absorbers were included (to remove carbon dioxide), suggested a similar device as a respirator for noxious atmospheres, invented the pneumatic trough for collecting gases, measured the size of the alveoli, calculated the surface area of the interior of the lung, calculated the time spent by the blood in a pulmonary capillary, invented the U-tube manometer, and measured intrathoracic pressures during normal and forced breathing. Hale's work is remarkable for its emphasis on the "statical" method, i.e., meticulous attention to detail in measurement and careful calculations. In his later life he made important contributions in the area of public health. He was a trustee of the new colony of Georgia and willed his own library of books to the colony though their whereabouts is unknown. He deserves more recognition in the history of respiratory physiology.