The emergence of medical specialties in the nineteenth century: a discussion of the historiography

 Alexander Silvester

Introduction

Medical specialization plays a key role in contemporary medicine. Theories of its’ emergence have been dominated by George Rosen’s (1944) account in the 1940s. in the 1940s’. Thus, George Weisz (2003) is surprised that the ‘major synthetic treatment of the subject is over sixty years old’. Weisz has highlighted that whilst the number of studies on the subject have increased in latter years, these works have investigated specific specialties, in specific countries, and in relatively narrow chronological time frames. Thus, Weisz argues that although this work has ‘cumulatively extended our knowledge of the specialization process’, many questions remain unanswered; including why did medical specialization first emerge when and where it did? Weisz’s apparent solution is to provide a ‘large scale account’ of specialization that includes national comparisons.

This essay aims to investigate the emergence of medical specialties in the nineteenth century and will use Rosen’s framework as a base to explore and revise the subject. Rosen argued that medical specialties emerged in the nineteenth century as a result of the shift to pathological anatomy, the emergence of medical technologies, and due to urbanisation. This essay will address each of these arguments in turn and will compare and contrast these with more recent scholarship on medical specialization. In particular, this essay will specifically look at Weisz’s synoptic analysis of national differences and Rosemary Stevens’ classic study (Stevens 1971) of the American case.

Anatomical localization

The concept of the ‘birth of the clinic’ is well established in historiography with acknowledged contributions from Erwin Ackerknecht (1967) and Michel Foucault (1973). The concept is associated with an apparent shift from Galenic humors to localized anatomy after the French Revolution. Liberal laws in early nineteenth century France allowed the use of unclaimed bodies for teaching purposes. In combination with the establishment of largely populated institutions, clinical medicine emerged as clinical signs were associated with post mortem findings. Furthermore, disease was no longer considered in terms of a balance of humors, specific organs were identified as the loci of disease and the foci for treatment. This concept of the clinic is not without its’ critics. Hannaway and Le Berge (1998) recently argued that the origins of the Paris clinic and localized pathology belong in the eighteenth rather than the nineteenth century. Furthermore, they have argued that it was not an exclusively French concept and that British medicine made major contributions. ‘Paris medicine received fertilization from British influences in pathological anatomy’ thus Keel (1985) has used the examples of John Hunter and Mathew Baillie as British influences on the concept. Nevertheless, whether or not there was a British contribution, there is no question that Paris had the institutional infrastructure and the medical community for localized pathology and consequently medical specialties to emerge. Thus the consensus is that medical specialties first emerged in nineteenth century Paris, the reasons for this are not, however, so well agreed.

Rosen argued that this new way of thinking, the shift to localized pathology, laid the groundwork for modern specialism, furthermore, Stanley Reiser (1978) asserts that it provided an ideological basis for specialism. Additionally Stevens (1971) argues that as the attention turned to particular organs and lesions, there was a growing need for facilities in which appropriate studies could be made. Thus, Stevens argues that ‘from this compelling movement… special hospitals grew.’ Similarly, Erwin Ackerknecht explains that the new pathological conception of disease that replaced humoral theory led to the advancement of medical specialties in the early nineteenth century. These historians argue that each organ provided a nucleus around which clinical and pathological research could gather, a focus of interest and further development. Rosen also argued that those studying a limited field of work received a more intensive training than those studying a wider range.

In contrast, Weisz argues that whilst localized pathology played a role in the emergence and further development of medical specialties, he argues that it was not a primary role. Furthermore, Weisz suggests that this role was not necessarily determinant, and argues that many specialties were not based on organic localism. Weisz quotes the example of L’Esculape, a medical journal devoted to specialties, which provides a list of medical specialties prevalent in 1839. Whilst examples of organically based specialisms are given, for example; medicine des yeux, maladies des voies urinaires, some were organized around specific populations e.g. children, the insane, others on therapeutic techniques, e.g. hernia surgery, spa medicine and others on what Weisz has classified as state needs e.g. public health, forensic medicine. Thus, Weisz (2003) concludes that it is not credible that specialties emerged simply as secondary effects of organic localism, but does not deny that organic localism ‘both stimulated the emergence and helped shape the form of many specialties that emerged’.

The argument that medical specialties emerged from the shift to localized pathology is credible. The timing and location of the emergence of medical specialties fits in well with that of the concept of the ‘Paris clinic’. However, the association is not so clear cut and perhaps not so simplistic. As Weisz has argued, there are some examples of specialties that have no direct correlation with localized pathology, particularly those organised around specific population groups and specific ‘state needs’. Furthermore, Hannaway and La Berge’s recent revision of the Paris clinic brings this argument into further doubt. If localized pathology emerged earlier and from a different country (eighteenth century Britain), it cannot, therefore, explain why medical specialization emerged in nineteenth century France. However, whilst Hannaway and La Berge’s work has attempted to question an older more established concept, the strength of the ‘Paris clinic’ argument remains and is evident with the institutional structures developed post the French Revolution that assisted with nosology.

Medical technologies

Timmermann (2006) has argued that since the 1980s, research has focused on the use of medical technologies and their impact on the development of medicine over the past two centuries. A medical technology has been defined by the US Office of Technology Assessment as the drugs, devices and medical and surgical procedures used in medical care, and the organizational and supportive systems within which such care is provided (Timmermans 2003). Rosen and Ackerknecht have argued the importance of medical technologies in the emergence and development of medical specialties and Rosen, in particular, has cited the examples of the ophthalmoscope and the laryngoscope and the development of ophthalmology and otolaryngology respectively. Thus Stevens argues that ophthalmology and otolaryngology developed around modern instruments as such technology was difficult to use and required special training. However, this argument is not accurate. The term ophthalmology was coined after Hermann von Helmholtz invented the ophthalmoscope in 1851, however, the study of eye disease pre-dates this. Rosen’s own account of medical specialties pays particular reference to ophthalmology and has provided evidence of numerous eye hospitals that were established in the early nineteenth century; including Moorfields in 1804, which clearly predates the ophthalmoscope. Therefore, in this example, the origins of the specialty predate the medical technology and in fact, the technology developed after the specialty had been well established. Furthermore, Lawrence (1985) has argued that British doctors were not so keen of new technologies and that when a few enthusiasts did adopt them, they were absorbed into generalist culture. For example, even though the ophthalmoscope emerged in 1851, by 1871 very few practitioners in England were using them and those that did, were not specialists but generalists. Lawrence uses the example of John Hughlings Jackson, the British neurologist, who wrote; “I write as a physician, and not as an ophthalmologist. I have studied ophthalmic medicine merely as a help to the study of diseases of the Nervous System.” Thus, medical technologies in this example, did not lead directly to the establishment of a medical specialty.

In contrast, Reiser (1978) argues that specialization was stimulated by the multiplication of scientific instruments and that the armoury of technological devices offered a material basis for the specialization of medical practice. However, Weisz argues that Rosen and others have concentrated too much on medical technologies and does not attribute primary responsibility to them. Weisz (2003) argues that like organic localism, new technologies at most provided ‘an axis along which certain specialties were able to develop.’ Furthermore, Lawrence has used the much later example of X-rays to emphasize that medical specialties did not emerge from medical technologies. Lawrence argues that in England, the discovery of X-rays did not result in the rapid development of radiology.

Gritzer (1985) asserts that this is not the case and that specialties are an extension of new knowledge and new techniques and is a natural process. Further, Henry Cohen said that “advancing knowledge must inevitably lead to specialisation in all fields” and Armstrong (1997) has highlighted that the natural argument is based on a belief that medical knowledge is ‘organic, growing and differentiating apparently of its own accord’. Weisz and Rosen have criticized the ‘natural growth model’, they argue that medical specialisation was not inevitable. Furthermore, Weisz (2003) asserts that the ‘common sense explanation’, that the rapid expansion of knowledge forced doctors to specialize, is incomplete. Thus, in contrast to the ‘natural model’, Gritzer (1985) has suggested a ‘market model’, which he explains as ‘the struggle among occupations to organize markets by gaining the exclusive right to exercise certain skills and perform certain tasks’. This is similar to Stevens’ main argument for the emergence of medical specialties in America in the nineteenth century. Stevens (2003) asserts that competition in voluntary hospitals was fierce and that vacancies were only available through retirement or death of an incumbent. Thus, aspiring (mainly junior) doctors who were frustrated with the concepts of the wide generalist medical culture, had to found their own specialist hospital. Pickstone (2001) and Armstrong (1976) have argued that medical practitioners searched out protected economic niches by taking a special interest in a particular part of the body. In contrast, Weisz does not fully agree with this argument, asserting that there is no reason to assume that doctors were notably more self-interested in the nineteenth century than they had been in the eighteenth. However, the concept of the Paris clinic and the emergence of localized pathology in the nineteenth century would explain this apparent disparity.

Thus Gritzer (1985) argues that knowledge and technology did not cause specialization but were resources ‘used by interested groups to justify specialty status and dominance in a division of labor’. Durkheim (1964) argued that a division of labor was a consequence of population density in cities, urbanisation.

 

Urbanisation

Urbanisation is a concept that refers to the growth of cities and is associated with the arguments of an industrial revolution. For Rosen, urbanisation was a key social development in medical specialties. Rosen (1944) argued that the emergence of specialties were ‘intimately related to urban concentration’ and that the city was of utmost ‘importance for the development of specialized skills and activities’. Rosen supports this argument by citing an article from the 1836 Boston Medical and Surgical Journal that complains that there was a large number of doctors densely concentrated in towns that there were not many patients to go around; “the fact is there are dozens of doctors in all great towns, who scarcely see a patient from Christmas-time to Christmas-time.” Furthermore, Rosen attributes such a relation to population and economic factors. For example, Rosen argues that urbanisation meant an increase in population and therefore increased the incidence of morbidity. Rosen suggests that specialties emerged around large-scale morbidity e.g. child epidemics in urban areas led to the emergence of paediatrics. Additionally, Rosen suggests that the various economic and social conditions resulting from the growth of a city resulted in specialist hospitals e.g. eye and ear hospitals. Stevens (2003) has argued that it was around these hospitals that the education and identification of specialties emerged and adds that it was the growth of cities and towns that fostered the formation of these hospitals. Weisz has suggested that specialization was an urban phenomenon and general demographic factors e.g. the growing density of doctors and patients in the cities, were important conditions. Weisz’s (1994) paper on the mapping of medical specialization has highlighted that medical specialties e.g. respiratory, digestive, and cardiovascular systems while so significant in elite Parisian institutions, were relatively undeveloped in the hospitals of provincial cities. Furthermore, Weisz’s (2006) recent work argues that the role of urbanisation is an insufficient explanation, citing the example of London, the largest city in Europe, which he argues was not associated with medical specialties. Weisz argues that Paris had the institutional infrastructure and research community that London did not have. Furthermore, Weisz attributes the emergence of specialties in Paris (and not Britain) to the unification of medicine and surgery in professional practice and medical education and research. Weisz (2003) asserts that ‘only in the context of a large and unified domain of medical knowledge did division into sub-fields make very much sense’. However, specialties did emerge in England in the nineteenth century at a time when medicine and surgery remained distinct (and rival) entities. Therefore, whilst the institutional infrastructure of institutions and the unification of medicine and surgery may have helped the early emergence of specialties in France, by not having these structures in place did not hinder the emergence of medical specialties in England.

Alternatively, an economic explanation may be more fruitful. Armstrong has raised the concept of the division of labor as at least a partial explanation for specialization. The term was coined by Adam Smith and developed by Durkheim (1964). Although Shephard (1990), in his account of the development of anaesthesia in Canada, has also asserted that specialization is a form of division of labor, Gritzer (1985) argued that it was a ‘sterile, apolitical concept that obscured how work was organized’. Furthermore, this account would suggest the inevitability of the emergence of medical specialties.

Urbanisation clearly played some role in the emergence of medical specialties. As the accounts above have shown, medical specialties in the form of specialist doctors and specialist hospitals emerged in cities, for example Paris, and London. Historians have explored the reasons for such an association that has included population issues and economic factors. It could be argued that urban areas tend to be more progressive and tolerant to change, and therefore, provided an excellent base for medical specialties to emerge. However, this argument does not hold up as it implies that medical specialties were progressive and furthermore, the majority of opposition to medical specialties in England could be found in London (albeit around the conservative elite institutions and the radical reformers).

Discussion

This essay aimed to explore Rosen’s landmark model of medical specialties and to analyse it with reference to recent scholarship in the subject. Rosen argued that medical specialties emerged in nineteenth century Paris and the key arguments to his model of their development have been identified as localised pathology, new medical technologies and urbanisation.

Rosen does not appear to rank his arguments or claim that one made the major contribution to the emergence of medical specialties in the nineteenth century. Thus Rosen (1944) asserts that ‘medical specialization resulted at least as much from general and social and economic influences as from scientific and technological factors within the medical field’. This suggests that issues relating to the emergence and development of medical specialties are complex and, perhaps, interwoven. Weisz’s large-scale study has shed more light on the matter and has questioned some of the key concepts of Rosen’s model, which have been held as fundamental over the last sixty years. Furthermore, although Weisz (1994) has suggested his own account of the emergence of medical specialties, he concludes that significant variations between specific specialties have ‘made it difficult for any single model utilizing social or intellectual factors (even in combination) to fully account for the historical diversity of specialization’. Therefore, although Weisz has been critical of studies that have investigated specific specialties in specific countries, after all, they might be the best way to explore specialization if single models have proved too difficult.

Although this essay has explored the key arguments to Rosen’s landmark concept of medical specialization, it has only looked at French and British medicine and has paid little attention to developments in Germany and the USA. Furthermore, this essay has not explored the opposition to medical specialty (particularly in London), in any detail, which provides a substantial argument for the development of medical specialties in Paris before London.

By reviewing the published work on this subject, it is clear that there is no consensus as to when a medical specialty becomes a medical specialty. Is it the establishment of a specialist hospital? Is it the formation of a specialist society or publishing a specialist journal? Thus, for example, the distinction between a ‘quack’ oculist, a surgeon oculist and an ophthalmologist are not so clear. Further scholarship, therefore, must not only look at specific specialties in specific locations, but must also make an attempt to define what a medical specialty was in the nineteenth century.

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