liana Lowy Ludwik Fleck on the social construction of medical knowledge

Abstract The subject of the development and transmission of medical knowledge has remained, until recently, relatively little studied by medical sociologists. But as early as the 1930s the pioneering studies of Ludwik Fleck, a physician and historian of science, dealt with the evolution of medical knowledge and the genesis of medical facts. Starting with a reflection on his own experience as clinical bacteriologist and immunologist. Fleck developed highly original views on subjects such as the influence of patterns of specialization of physicians on the medical knowledge they produced, the impact of popular models of disease on expert ones, and the importance of the circulation of ideas between distinct, and - according to Fleck incommensurable 'thought collectives' (medical scientists, general practitioners and patients) for the development of innovations in medicine. The aim of this article is to analyze Fleck's vision of medicine and to select among his ideas those which may be of interest for sociologists of medicine today.

Introduction

The sociology of health and illness is concerned with a wide range of subjects dealing with the ways society takes care of its sick members. One subject is, however, often missing from the evergrowing list of topics studied by sociologists: the impact of society on the development of present medical knowledge. Until recently, sociologists dealing with medical subjects have usually separated issues concerning the behaviour of physicians and their knowledge. Although they have examined the infiuence of society on the development of medical knowledge in primitive and folk medicine and in the past, they have often made an absolute distinction between this 'non-scientific medical knowledge' and modem scientific Sociology of Health & Illness Vol.10 No. 2 1988 ISSN0141-9889

134 liana Lowy

medicine. Modern medical knowledge has been viewed in many works of medical sociology as homogeneous, culture-independent and founded on objective observation and experimentation (King 1962: 93; Freeman, Levine and Reeder 1972: x-xi; Albrecht and Higgins 1979: 7-10). The hesitations of medical sociologists in applying their usual methods of investigation to the study of the formation and evolution of present medical knowledge refiected perhaps their lack of competence on medical topics on the one hand, and their professional strategy of aspiring to recognition by physicians on the other (Kendall and Reader 1972: 1-21; Strong 1984). In the last ten years, however, several studies have dealt with the influence of society on the evolution of medical science. The recent development of social studies of science, and increased interest in the social construction of scientific knowledge (Bloor 1976; Knorr, Krohn and Whitley 1981, Knorr and Mulkay 1982) have inspired studies dealing with the social construction of medical knowledge (e.g. Wright and Treacher 1982; Figlio 1982; Gabbay 1982; Amstrong 1983. For a review see Bury 1986; Nicolson and McLaughin 1987). Another recent evolution has been the formation of a new specialty: the philosophy of medicine. This deals, among other things, with the specificity of medical knowledge and its relationship to biology and the natural sciences in general (Gorvitz and Maclntyre 1976; MauU 1981, Schaffner 1986; Caplan 1986). The developments of the last years cannot, however, in my opinion, justify the idea that the sociology of biomedical research already exists. Rather, I would agree with Renee Fox who recently affirmed that: 'For many years, I have been amazed at the virtual absence of first-hand sociology of medical studies' (Fox 1985). Philosophers have attempted to define the overall conceptual framework of medicine and have not studied the impact of societal factors on the evolution of medical knowledge in concrete cases. Sociologists who have approached this subject have often been more interested in the relationships between social models of health and illness and the professional strategies of doctors than in the development of medical knowledge itself.

Ludwik Fleck's philosophy and sociology of science

The problem of the impact of society on the genesis of medical knowledge was addressed as early as the 1920s and 30s, when a

Ludwik Fleck

135

highly original attempt to study it was made by a Polish-Jewish physician, Ludwik Fleck (1896-1961). Fleck, a bacteriologist and immunologist, combined strong philosophical and sociological interests with medical training and long practice in a clinical laboratory. For many years his works remained practically unnoticed by historians, philosophers and sociologists of science. They were rediscovered after the publication of The Structure of Scientific Revolutions., where in the introduction Kuhn cites Fleck's Genesis and Development of a Scientific Fact (Fleck 1935a) among the works that influenced his own thought (Kuhn 1962: viii-ix). In his epistemological works Fleck developed the notion that scientific knowledge is constructed. For him, alleged scientific 'facts' do not exist 'out there' in nature waiting to be discovered by objective and interchangeable observers. Rather, they emerge as thefinalresult of a social process: the 'genesis and development of a scientific fact'. The observer's training, his preconceived ideas, and his anticipations play a substantial role. Moreover, for Fleck scientific facts are constructed by distinct 'thought collectives', each composed of individuals who share a specific 'thought style'. Different and equally well-founded 'thought styles' can co-exist in a given domain, not only diachronically, in distinct historical periods, but also synchronically and within the same cultural universe. Fleck's approach was therefore at least partially relativist: not only is scientific knowledge constructed, but speaking of truth and falsehood is meaningful only within a specific thought collective and with respect to a given thought style. He was not, however, a complete relativist (although his work is sometimes represented as such). Fleck did not believe that observations are radically theoryladen and he considered science as capable of cumulative improvement (Fleck 1929; 1935c; Toulmin 1986). Today the majority of historians and philosophers of science agree that in science theory and observation are interdependent. This was certainly not the case in the 1920s and 30s, when epistemology and the philosophy of science in many countries (including Poland) was dominated by positivism. But not all historians and philosophers of science adhered to positivistic approach. A conventionalist approach to the philosophy of science, stressing the conventional nature of all scientific knowledge, was developed, probably as a response to the crisis in physics, at the beginning of the 20th century (H. Poincare, P. Duhem) and developed by historians of science (Metzger, Koyre). The conventionalist point of view also had adherents among Polish philosophers of science in

136 liana Lowy

the 1920s and 30s (K. Adjukiewicz, E. Poznanski, A. Wundheiler). Historians of culture, art and ideas of that period readily viewed science as but one aspect of the general creativity of human beings, and as such dependent on the wider socio-cultural context (Lovejoy 1936; Panofsky 1940). Some historians of science (H. Metzger, F. Enriques) shared this view and stressed the crucial importance of studying the science of past periods in its philosophical, cultural and social contexts. According to Metzger the historian of science should 'make himself the contemporary of the scientists he is studying' (Metzger 1933). Similarly, historians of medicine working in the 1920s in the influential Institute for the History of Medicine in Leipzig (H. Sigerist and his students, among them O. Temkin, E. Ackerknecht, and also the Polish historian of medicine T. Bilikiewicz) developed a similar approach. Influenced by German historicism, they claimed that the medicine of a given historical period should be studied only from the point of view of the period in which it was developed and that one should avoid the temptation of making modem judgments on past science (Temkin 1977). If conventionism in philosophy and historical relativism in the history of medicine existed already (albeit as minority trends) in the 1920s and 30s, and if representatives of these trends were present in Poland in the period during which Fleck published his major epistemological studies, why did his works remain practically unknown for such a long time? In the 1920s and 30s the history and philosophy of medicine were estabhshed academic disciplines in Poland. In all probabiUty, Fleck aspired therefore to be recognized by the historians and philosophers of medicine of his country. However, even the historians of medicine who acknowledged that past medical knowledge was strongly influenced by the cultural context in which it had been developed were not ready to accept Fleck's radical claim that modem, 'scientific' medicine is as dependent on social and cultural factors as the medicine of the past (Bilikiewicz 1939). As to the reason for the ignoring of Fleck's studies by Polish philosophers of science, several answers have been proposed: a) Fleck's approach was not new when considered against the background of Polish philosophy in the thirties: philosophers affected by the conventionalist tradition were in agreement with the conventionalist components of Fleck's philosophy, but felt that they had little to learn from him, while those who rejected conventionalism found his views unconvincing (Giedymn 1986); b) Polish philosophy of this period

Ludwik Fleck 137

developed a very high logical-methodological standard for what was considered worthy of discussion in epistemology; Fleck's writings could not satisfy this because his style of thought was incompatible with the dominant style of the Warsaw-Lwow philosophical school (Wolniewicz 1986). This last point merits further discussion. Why was Fleck's style so different from the one which dominated Polish philosophy of science in his time? The reason, I suggest, is that it was developed independently of this philosophy. Indeed, as I have argued elsewhere (Lowy 1986), Fleck's epistemology has its roots not in his philosophical training but rather in his scientific and medical practice. Taking his own clinical laboratory practice as a starting point for his epistemological reflections. Fleck did not ask what science must be, but attempted to investigate what science actually is and how historial processes and social institutions are related to the emergence of scientific 'facts'. In doing so Fleck broke radically with the idea, predominant in the philosophy of science in the 1920s and 30s, that philosophers are required to 'justify' science and to provide it with intellectual 'foundations'; instead. Fleck proposed an empirical research program for epistemology (Toulmin 1986). Fleck's preoccupation with the ways science in fact operates alienated him from the community of philosophers of science of his time. However, it is precisely this preoccupation that has made Fleck so relevant for the sociology of science in the last two decades. As Barnes and Edge put it: We do possess onefinepre-war work in the sociology of knowledge tradition which considered in detail the emergence of an accepted set of scientific doctrines and techniques. Ludwik Fleck's 'Genesis and Development of a Scientific Fact' (1935), recently rescued from oblivion, has been recognized as a major contribution. But that an extended study of such insight and importance was largely passed over upon its first appearance merely reinforces the point already made: there was widespread reticence to investigate the basis of anything considered to be genuine knowledge (Barnes and-Edge, 1982,65). And because the 'set of accepted doctrines and techniques' studied in great detail by Fleck in his magnum opus was, in his words, 'one of the best established medical facts: the fact that the so-called Wasserman rection is related to syphilis' (Fleck 1935a: xxviii), his studies are of special interest for sociologists of medicine.

138 liana Lowy

The importance of medical examples in Fleck's works

Ludwik Fleck is viewed today as a pioneer of constructivist epistemology and of the sociology of the natural sciences. For this reason, although all his sociological and philosophical studies principally used examples taken from the history and the practice of medicine, his works are read almost exclusively by philosophers and sociologists of science, not by sociologists or philosophers of medicine. Even the few articles dealing with Fleck's views on medicine have discussed Fleck's general philosophical position and made no specific comments on his detailed descriptions and analyses of medical practice (Sadegh-Zadeh 1981; McCoullogh 1981), and medical sociologists have quoted Fleck's book as an example of a 'general discussion of the sociology of science' (Lipton and Hershaft 1985). The numerous medical examples in Fleck's works have been, as far as I know, examined only in the framework of studies of his overall epistemological thesis. In my opinion, this is unfortunate. Fleck was the author of original reflections on subjects such as the growth and the diffusion of medical knowledge, the influence of popular models of disease on expert ones, the relationships between laboratory and clinics, and the mechanisms of specialization in medicine. I consider many of these pioneering reflections of sufficient value to be studied for their own sake, and not only as illustrations of a general philosophical or sociological thesis. My aim is therefore to analyze Fleck's vision of medicine, and to select among his ideas those that I consider of interest for sociologists of medicine today. In doing so I am aware of the fact that my presentation of Fleck's reflections, which stresses the potential value of his ideas for the study of the specific problem of the growth of medical knowledge rather than the more general problem of the evolution of scientific knowledge, is not entirely faithful to Fleck's original intentions. Fleck based his reflections, at least as far as modern science is concerned, on examples taken almost exclusively from his own scientific discipline. His first epistemological study was an article on the specificity of medical thought. But later on, he enlarged the scope of his reflections to all the natural sciences and he used the formation of medical knowledge as but one example of scientific knowledge in general. Fleck himself recognized, however, that his reflections on the social origins of cognition were particularly well adapted to studies of the development of medical knowledge. For him 'medical problems, concerned as they are with Man's more

Ludwik Fleck

139

highly prized possessions - his life and well-being - have an individual and social significance such as is not directly within the provenance of any physical or chemical problem. ( . . . ) This is why medical science is more suitable for the investigation of the social conditioning of cognition and acquired knowledge' (Fleck 1935b). In addition. Fleck's most important work. Genesis and Development of a Scientific Fact, is a detailed study of the development of a serological reaction for diagnosis of syphilis, i.e. a study of the application of fundamental immunological knowledge to practical medical needs. He founded many of his theoretical reflections on this example. For this reason, many of Fleck's ideas are, in my view, of particular pertinence to studies of interactions between fundamental research and its practical applications in general, and more specifically to studies of the development of medical knowledge.

Flecks ideas on medicine: The social origins of the disease concept

According to Fleck, the concept of disease is socially constructed. Inspired, in all probability, by the works of anthropologists (Fleck 1935a: 46), he claimed that different cultures have different ideas of health and disease: There are cultures, as for example the Chinese culture, which in _ important fields, such as medicine, arrived at quite different realities from those of us westerners. Shall we punish them for this with pity? They have had a different history, different aspirations and demands that are decisive for their cognition (Fleck, 1929). Within Western civilisation, too, the definition and the understanding of a given disease has varied over time. The first chapter of Fleck's book is dedicated to the analysis of the evolution of medical definitions of syphilis in different historical periods, from the Middle Ages up to the present time. Syphilis was first defined as lues venerea. This definition did not differentiate between various venereal diseases, and did not include tertiary syphilis. Later another, pharmacologically-inspired, approach was developed, which included syphilis among the diseases that were cured by mercury. Finally, at the beginning of the 20th century the etiological definition of infectious disease isolated a specific set of pathological symptoms that were united in a single disease concept 'syphilis', because all of them were induced by the same microorganism, Treponema pallidum (Fleck 1935a: 1-20). The different definitions of syphilis in

140 liana Lowy

distinct historical periods were, according to Fleck, deeply influenced by the dominant beliefs and traditions of a given time and 'the specific state of mind of a given society was the first and the most decisive factor that allowed the manifestations of morbus proteiformis to be transformed into a single unit, a well defined concept' (Fleck 1934). Fleck did not limit these ideas to past definitions of disease. For him, present definitions were equally historically-conditioned. 'They are the way they are because of just this particular history. Even the modern concept of the disease entity, for example, is an outcome of precisely such a development, and by no means the only logical possibility'. And, 'as history shows, it is feasible to introduce completely different classifications of disease' (Fleck 1935a: 21).
On incommensurability in medicine

According to Fleck, the classification of diseases is not a 'natural' one, referring to entities existing 'out there' and awaiting to be discovered. For him, 'The so called diagnosis - thefillingof a result into a system of distinct disease entities - is the goal and this assumes that such entities actually exist and that they are accessible to analytical method' (Fleck, 1935a: 64). Diseases are 'ideal, fictitious pictures, known as morbid units, round which both the individual and the variable morbid phenomena are grouped, without, however, ever corresponding completely to them (Fleck 1927). Moreover, according to Fleck, such different 'fictitious pictures', i.e. different concepts of disease, do coexist, not only in different cultures but also inside a given culture. The coexistence of different concepts of disease is the consequence of the very nature of the subject. Because of the complexity and the highly individual character of pathological phenomena, it is impossible to reduce pathology to physics, chemistry or even to biology. To the already great difficulties of the study of normal living organisms, pathology adds the supplementary ones of multifactorial and time-dependent phenomena. It implies, therefore, according to Fleck, a higher level of complexity, and in consequence a higher degree of indeterminance than biology. He affirmed that no simple causal relationship (that can be expressed as Cartesian coordiantes) exists in medicine, and in order to understand complex phenomena, such as disease, one needs to apply the principle of indeterminance developed by the theory of relativity (Elkana 1986):

Ludwik Fleck 141 Let me use afigurativecomparison: medical thinking differs in principle from scientific thinking in that it uses Gauss's coordinate system, while the latter uses the Cartesian system. Medical observation is not a point but a small circle. (...) A certain correction is introduced into the picture by the fact that, strictly speaking, the multiplicity of medical phenomena can be only approximately rendered by means of Gauss system since its points are not univocally determinable. To all intents and purposes, scientific thinking uses, for small ranges, the Cartesian system, and for large ranges Gauss's system (as in the theory of relativity). On the contrary, medical thinking uses Gauss's system for small ranges, while in the entirety it does not find any consistent and rational way to grasp phenomena. The impossibility of elaborating a global medical theory which allows for understanding of all the observed phenomena, 'like the atomic theory in chemistry or energetics in physics', makes impossible the development of a single approach to disease: Neither cellular nor humoral theory, nor the functional understanding of diseases alone, nor their 'psychogenic' conditioning, by themselves will exhaust the entire wealth of morbid phenomena. . . . this results in the incommesurability of ideas which develop from the varying ways of grasping morbid phenomena, and which give rise to the fact that a uniform understanding of morbidity is impossible (Fleck 1927). For Fleck, this incommensurability of ideas in medicine is not only a theoretical concept. It has practical consequences. Scientific facts are socially constructed by distinct 'thought collectives', each composed of individuals who share a specific 'thought style', incommensurable with others. This makes communication between the different thought collectives difficult. Moreover, in practice, the adoption of a given thought style excludes the simultaneous adoption of a different one: according to Fleck, although a physician can relatively easily reconcile his practice with an interest in the history of medicine, it is much more difficult to reconcile clinical practice and a reductionist point of view: It happens more frequently that a physician simultaneously pursues studies of a disease from a clinical-medical or bacteriological viewpoint together with that of the history of civilisation, than from a clinicalmedical or bacteriological one together with a purely chemical one (Fleck 1935a: 111). The importance of training for the adoption of a given 'thought style' Differences in ways of understanding a given problem or even

142 liana Lowy

observing a given object according to an adopted thought style also exist, according to Fleck, among the different medical specialities: The art of observation is not a general one; it does not include all fields of science at the same time. On the contrary, it is always limited to one field only. I knew an eminent surgeon, specializing in the abdomen cavity, who needed only just a few looks and a few touches of the abdomen to diagnose the clinical state of the apendix vermiformis almost infallibly, sometimes in cases when other medical men 'did not see anything'. The same specialist could never learn how to distinguish under the microscope mucus strips from the hyaline cast. I also knew a bacteriologist who was an assistant lecturer in a large university; he perceived and recognized ever so minute morbid changes in inoculated animals, but was unable to tell a male mouse from a female one. (Fleck 1935c) Probably under the influence of the Gestalt psychology (Schnelle 1986), Fleck developed the idea that the capacity of observation is acquired largely through a learning process. He therefore explained the differences in the perception of medical specialists by differences in their training: One has first to learn to look in order to be able to see that which forms the basis of a given discipline. (...) Still more vivid is the necessity of a special training to acquire the ability to perceive certain forms e.g. in dermatology. In this field, a layman who is capable of carrying out good observations in other domains, say, a specialist in bacteriology, does not differentiate and recognize dermatological changes. At first he listens to the descriptions of dermatologists as if they were fairy tales, much as he has the described object lying in front of him. (Fleck 1935c). During their training and specialization future specialists adopt a given thought style and learn to see reality in accord with it. A beginning student looking at a microscopic preparation of bacteria has no idea what he is supposed to observe there. A long training is needed to teach him to be able to 'see' the right picture (i.e. for Fleck, one in agreement with the current bacteriological tradition). Moreover, and this point is crucial to the understanding of Fleck's concept of incommensurability, training in one thought style hampers one's ability to look at the same object from a different point of view: One could believe that the hypothetical research worker of Poincare, while having an infinite time at his disposal, would be simply a specialist of all trades, all sciences, thus being able to perceive specific forms in all fields. However, this is psychological nonsense, since we know that the

Ludwik Fleck 143 formation of powers of perceiving certain forms is accompanied by the vanishing of the faculties of perceiving some others. (. ..) A physician who is professionally trained in observing the ever-changeable and whimsical pathological forms is, as a rule, a poor observer of continually recurring regular phenomena: he is not interested in them, nor does he notice them, nor ought he to notice them if he is to be a good pathologist. (Fleck 1935c). During the process of specialisation in medicine, knowledge is gained and lost: Physicians know that a dermatologist observes different things than a general practitioner. A general practitioner is unable to see the tiny modifications in the skin's surface, but is trained to perceive the general habitus of a patient, and can observe many things about him, invisible for the dermatologist (Fleck 1934).

Each medical specialist is able to observe pathological phenomena only in the framework of the specific thought style in which he was trained. And each thought style 'made possible the perception of many forms, as well as the establishment of many applicable facts. But it also rendered the recognition of other forms and other facts impossible' (Fleck 1935a: 93). To sum up, for Fleck the intrinsic complexity of the subject matter of medicine - human disease - makes necessary the coexistence of several distinct and incommensurable thought styles dealing with pathological phenomena. Their incommensurability can be explained at the cognitive level by the impossibility of finding a single explanatory theory able to embody the whole richness of pathological phenomena, and at the sociological level, by the process of specialization in medicine, during which the increase in capacity to recognize some phenomena is necessarily accompanied by the loss of the ability to perceive others.

Purpose-dependency of scientific truths and the medical way of thinking

Medicine is a 'practical science' and, according to Fleck, its practical goals influence the development of medical knowledge. He illustrated this claim by an example taken from bacteriology. According to him, in bacteriology two distinct thought styles coexist: the botanical-genetic and the medical-epidemiological. The bacteriologists involved in botanical-genetic (i.e. scientific) studies of

144 liana Lowy

bacteria have a tendency to use stringent biochemical criteria in the classification of bacteria. They prefer to have false negative results, rather than false positive ones. Epidemiologists, conversely, prefer to have less stringent criteria, as they wish above all to avoid false negative results and the non-recognition of a potentially dangerous bacterium. Fleck quotes a study in which, during an epidemic of scarlet fever the epidemiologists, using their criteria, classified 100 per cent of the bacteria involved as Streptococcus haemoliticus. When the same bacteria were studied with the more stringent criteria of fundamental bacteriology, only 84 per cent of them were so defined. This story served for Fleck to illustrate 'the purposedependency of scientific truths'. For him the medical-epidemiological thought style is as legitimate as the botanical-genetic one; therefore, both results are correct, and 'one arrives at divergent and not interchangeable truths' (Fleck 1929). Each one will be valid within the thought style that generated it. The truth of the fundamental scientist is not, however, identical with the truth of a practicing medical bacteriologist.
Medical practice and the problem of communication between thought collectives What then can be done, when representatives of two distinct thought styles, holding these divergent and non-interchangeable truths, need to communicate? This is a frequent situation in medicine. General practitioners need the specialist's information and they have to communicate it to patients. But, according to Fleck, patients (i.e. lay persons), general practitioners and specialists belong to different thought collectives and have distinct, incommensurable thought styles. Fleck analyses this situation through a concrete example: the diagnosis of diphtheria. An expert bacteriologist discussing with another expert a specimen from a throat swab will indicate that many, but not all, of the bacteria in the studied preparation have the characteristics of Loffler baccilus, the etiological agent of diphtheria: Numerous bacilli, many of them club-shaped and slightly curved (...) their arrangement is in several placesfinger-and pallisade- shaped, elsewhere irregular (...) Loffler methyl blue: many lacerated bacilli (...) sharply defined colonies, in which bacilli were found mostly typical in their staining characteristics, morphology and arrangement. The expert's conclusion, as formulated for his peers is that in view of the

Ludwik Fleck

145

origin of the examined material, and the morphological and culture characteristic of the bacilli, the diagnosis of Loffler baccili seems sufficiently well established (italics mine) (Fleck, 1935a: 113). For Fleck this is the presentation of an extremely simplified case. From his experience as a bacteriologist he knows that it is rare to find that everything is in such perfect agreement. Often the arrangement of bacilli is not so typical, the staining is not so unambiguous and the culture may contradict the microscopic specimen. But, even in the described ideal case, when the expert can be as certain as possible that he is indeed dealing with diphtheria baccili, the answer, formulated in the language of his specialty, would not, according to Fleck, appeal to a general practitioner expecting a firm diagnosis. He may claim: 'I just asked you what this throat swab really contains, and you reply: because it is a throat swab the conclusion is justified that it is diphtheria. That is being mischievous. I wanted your support, but you used me to support yourself. Thus, the specialist would formulate a different description for the general practitioner: 'the microscopic specimen shows numerous small rods whose shape and positions correspond to those of diphtheria bacilli. Cultures grown from them produced typical Loffier bacilli'. And to the patient the description will be even shorter: the doctor will simply state that he has diphtheria (Fleck 1935a: 114). For Fleck, the specialists (the esoteric circle) and the general practitioners (the exoteric circle) belong to distinct thought collectives. Ideas that circulate among thought collectives are bound to change during this process. The uncertainty of the knowledge of specialists is converted by the migration of ideas through the collectives into a heuristic vademecum science. It is characterized by the omission of detail and of controversial opinions which produces an artificial simplification. The 'genesis and development of a scientific fact' described by Fleck - in this case the unambiguous affirmation that a given person is suffering from diphtheria - is the result of the circulation of ideas through thought collectives (Fleck 1935a: 11213; 119).
Popular repr^entations of disease, vademecum science and expert medical knowledge

According to Fleck, the circulation of ideas between thought collectives is not one-sided. Scientific knowledge, when transformed

146 liana Lowy

into vademecum knowledge 'shapes specific public opinion as well as the Weltanschauung and in this form reacts in turn upon the expert' (Fleck 1935a: 113). The main topic of Fleck's principal work. Genesis and Development of Scientific Fact is a study of the influence of society on the formation of a specific 'medical fact': the elaboration of the Wassermann serological test for syphilis. Fleck's main claim is that popular belief in the existence of 'syphilitic blood' provided a strong stimulus for the development of a blood test for the diagnosis of syphilis. During the elaboration of this test, the first experimental results were, according to Fleck, far from encouraging. In addition, the results could not be fully explained by the immunological knowledge of that time. But the authors of the test persisted, and after many efforts were able to develop, by trial-anderror, a functional blood test. Fleck explains the persistence of the scientists, facing inexplicable findings and initial failures, by the influence of the centuries-long popular belief that syphilis induces specific modifications in the blood (Fleck 1935a: 11-13). In the early 19th century, well before the discovery of specific antibodies in the serum, physicians tried to find chemical morphological modifications in the blood of syphilitic patients: With amazing and unprecedented persistence, all possible methods were tried to confirm and to realize the traditional concept of syphilitic blood. It was with the so-called Wassermann reaction that the success was at long last achieved (Fleck 1935a: 14). This success was due to the existence of the popular belief: Had it not been for the insistent clamor of public opinion for a blood test, the experiments of Wassermann would never have enjoyed the social response that was absolutely essential to the development of the reaction, to its 'technical perfection' and to the gathering of collective experience' (Fleck, 1935a: 77). However, the process did not come to an end at that point. Popular knowledge contributed to the formation of expert medical knowledge, but later the newly formed expert knowledge was translated into a generally accepted vademecum knowledge. The translation process is obligatory in medicine because this discipline needs to use fundamental scientific knowledge for the practical goals of diagnosis and healing. In another part of his study of the origins and development of the Wassermann reaction. Fleck describes how expert medical knowledge in this field became codified and simplified, and achieved the status of vademecum knowledge. The

Ludwik Fleck

147

selection, adaptation, simplification and transformation processes necessary to accomplish this are made visible by Fleck by comparing the first articles published by Wassermann and his collaborators in scientific journals (expert knowledge or 'journal science'), with the simplified and codified representations of the Wassermann reaction in textbooks destined for clinical laboratory practice {vademecum knowledge) (Fleck 1935a: 70-6). When the expert knowledge became vademecum knowledge, i.e. was transformed into a 'scientific fact', it acquired the capacity to modify the perception of reality of those who utilized it: In the history ofthe Wassermann reaction, we described the process by which personal and provisional journal science becomes transformed into collective, generally valid vademecum science. This appears initially both as a change in conceptual meaning and as a reformulation of a problem, and subsequently as accumulation of the collective experience, the formation of a special readiness for directed perception and specialized assimilation of what had been perceived (Fleck 1935a: 120). Fleck develops a highly dynamic vision of the formation of medical knowledge, in which expert knowledge is influenced by popular knowledge, and then influences it in turn. According to him, the modification and transformation of ideas is the obligatory result of their circulation through distinct thought collectives holding incommensurable 'thought styles'. This modification of ideas has an important positive effect. When an idea belonging to a given thought style is transposed to a different one, it'predominantly fertilizes and enriches the alien style, while being altered and assimilated: the content changes sometimes beyond recognition even if the word has remained unchanged' (Fleck 1936). It can therefore be at the origin of an innovation: The intercoUective communication of ideas always results in a shift or a change in the currency of thought (...) The change in thought style, that is the change in readiness for directed perception offers new possibilities of discovery and creates new facts (Fleck 1935a: 109-10). In this way the old popular idea of 'syphilitic blood', when transposed to a new thought collective - bacteriologists and immunologists - allowed the development of an important innovation: the Wassermann test. To sum up: for Fleck, medical knowledge by its very nature cannot remain an 'expert knowledge' confined to the Umited thought collective of fundamental scientists. It needs to transform

148 liana Lowy

itself into a heuristic vademecum science, and to get into close contact with popular representations of disease. The inevitable transformations of expert medical knowledge that occur during the social process of its transmission and adaptation to the concrete needs of medical practice can be at the origin of important conceptual modifications and can lead to innovations in medicine.
Fleck's particular viewpoint

My hypothesis is that Fleck's ability to formulate a philosophical and sociological approach to the evolution of medical knowledge has its roots in the particularities of his professional situation at the time he elaborated his theoretical views. In particular his own career, with a foot in medical practice and experience in scientific research, sensitised him, in all probability, to the disparities in thought style between different collectives (the 'clinical-medical' or 'bacteriological' versus the 'purely chemical' viewpoint) and thus examplified his own thesis. Fleck was trained as a physician, but immediately after the end of his medical studies (in 1920) turned to fundamental research in bacteriology and immunology. He failed, however, to secure himself a position as a scientist, and was obhged to adopt a different professional role: that of clinical microbiologist and immunologist. He was unable to keep his position at the Lwow University (probably either because of personal problems, or,the antisemitism prevailing at that time in Lwow, or both) and from 1923 to 1939 he worked in several routine analysis laboratories. Fleck considered this situation as a temporary one and hoped to return to his true vocation: fundamental scientific research. He finally succeeded in doing so after the Second World War. During the years in which Fleck developed his epistemological ideas (1926-39) he dealt almost exclusively with practical questions and had limited, if any, recognition by fellow scientists. On the other hand he continued to view himself as a fundamental scientist. He pursued his scientific research during his free time, and hoped to return to the scientific community (Schnelle 1986). Although Fleck did not claim explicitly that his reflections were based upon empirical studies, his professional experience allowed him to use concrete and detailed examples taken from the daily practice of a clinic, a hospital, a medical analysis laboratory. In addition. Fleck's marginal professional position during the period of

Ludwik Fleck 149

the evolution of his theoretical thought seems to have favored his ability to observe the development and the uses of medical knowledge. His viewpoint was simultaneously an 'inside' and an 'outside' one. It allowed him to combine the advantages of an internal participant with those of an external observer. His specific position - a fundamental scientist in a temporary (so he hoped) 'exile' among practitioners - made it easier for him to observe the shortcomings and the difficulties of the application of science to medicine. At the same time, his professional position gave him an intimate internal knowledge of what medical science is really about, and how it functions.

Conclusion

In this study I have tried to show the potential importance of Fleck's ideas for a sociological approach to studies of the formation of medical knowledge. Reck was among the first to postulate the social origins of concepts such as health and disease, normal and pathological. He explained, as many sociologists did later, that diseases are social constructions. But while medical sociologists have usually stressed the impact of societal factors on the construction of models of disease by patients (Zborowski 1953; Zola 1963; Good and Delvecchio-Good 1981: 165-96; Mechanic 1982; d'Houtaud and Field 1984), Fleck was more interested in the study of the impact of these factors on the construction of the disease concept by
physicians.

Through the detailed analysis of concrete examples taken from his professional experience, Fleck tried to explain some of the mechanisms through which society can affect the process of construction of medical knowledge. Some of these mechanisms have been studied by medical sociologists: the subject of the training of physicians and of their specialization and the effects of medical training on doctors' professional behaviour was one of the 'classical' themes (Merton, etal. 1957; Becker, etal., 1961; Kendall and Selvin 1966; Friedson 1970, Bosk 1979, Atkinson 1984). Today, probably under the influence of Kuhn's ideas concerning the effects of training in shaping scientific observation (Kuhn 1962), the impact of patterns of specialisation in medicine on the nature of medical knowledge produced by physicians is also studied (Figlio 1982, Gabbay 1982). These studies, although they usually represent a more sociologial point of view than Fleck's epistomologically-

150 liana Lowy

oriented approach, can be viewed as a continuation of the research program which he sketched. However, Fleck's other ideas, e.g. the incomensurability of ideas expressed by different thought collectives, the interactions between journal knowledge, textbook knowledge and popular knowledge, and the transformation and modification of ideas during their circulation through distinct thought collectives, have rarely been developed. The differences between popular models of disease and scientific ones have been studied, but usually in order to explain the difficulties in communication between doctors and patients (Loux 1978: 311-15; Tuckett and Williams 1984; Tuckett, Boulton and Olson 1985). In addition, although some of these works have looked for a possible impact of scientific models of disease on popular ones (Samora, Saunders and Larson 1966, 292-301; Svarstad 1979; Morgan and Spanish 1985), less attention has been paid to a possible reverse influence. Fleck, a convinced holist, claimed that the formation of medical knowledge was a time-dependent, dynamic process including many complex interactions and involving not only the limited circle of medical experts but society as a whole. Only the combination of historical, sociological and philosophical approaches into a multidisciplinary approach, called by him 'comparative epistemology', could allow for a proper study of such a complex phenomenon (Fleck 1935a: 22-3; 51). The detailed medical examples in his writings give us a glimpse of such a multidisciplinary approach to the study of the social genesis of medical knowledge. On the other hand Fleck's concept of complex dynamic interractions and mutual influences between popular science, vademecum knowledge and expert medical knowledge can perhaps contribute to a better understanding of the development of both scientific and lay models of disease. This may be of particular importance in studies of diseases which have a strong social impact, such as cancer or AIDS. Fleck's epistemological writings suffer, in my opinion, from several imperfections. They are in many aspects closer to a draft than to a completed theory (Baldamus 1977; Harwood 1986). Some of the fundamental philosophical questions are not clearly answered and the meaning of the expressions 'thought collective' and 'thought style' fluctuates in different contexts. These imperfections can be at least partially explained by difficult conditions: life in a provincial town, a marginal institutional position, and lack of contacts with philosophers and historians of science. The imperfections of his work notwithstanding. Fleck had the

Ludwik Fleck 151

undoubted merit of being among the first to ask fundamental questions about the social origins of scientific knowledge, and trace some of the possible directions in which one can look for answers to these questions. Moreover, many of his ideas can be tested with sociological methods. In his forward to the English translation of Genesis and Development of a Scientific Fact, T. Khun affirmed that many of the issues evoked in this book 'merit much additional consideration, not the least because they can be approached empirically. ( . . . ) Fleck opens avenues for empirical research' (Kuhn 1979: ix-x). In this article I have tried to show that this suggestion can be particularly fruitful for sociologists interested in medicine and in medical science. Fleck should not be viewed by them as a hitherto 'unacknowledged precursor' brought to light by zealous historians of science (Metzger 1937), but as an author who invites them to future reflection and study. INSERM U-158 Pavilion Archamboult Hopital des Infants Malades 149 Rue de Sevres 75743 Paris Cedex 15
References
Albrecht, G.L. & Higgins, P.C. (eds) (1979) Health, Illness and Medicine: A Reader in Medical Sociology. Boston: Houghton Mifflin Company. Armstrong, D. (1983) Political Anatomy of the Body. Cambridge: Cambridge University Press. Atkinson, P. (1984) 'Training for certainty'. Social Science and Medicine, 19 (9), 949-56. Baldamus, W. (1977) 'Ludwik Fleck and the development of the sociology of science', in P.R. Gleichman, J. Gouldsblom and H. Korte (eds), Human Pigurations: Essays for Norbert Elias. Amsterdam: Amsterdam Socialogisch Tijdschrift, 135-56. Barnes, B. & Edge, D. (eds) (1982) Science in Context: Readings in the Sociology of Science. Cambridge, Mass.: The MIT Press. Becker, H.S., GeerB., Hughes, E.C. and Strauss, A.L. (1%1), Boys in White. Chicago: University of Chicago Press. Bilikiewicz, T. (1939) 'Uwagi nad artykulem Ludwika Flecka 'Nauka i srododowisko' (Some remarks on the article of Ludwik Fleck 'Science and Environment'), Przeglad Wspolczesny, 18,9-20. Bloor, D. (1976) Knowledge and Social Imagery. London: Routledge and Kegan Paul. Bosk, C.L. (1979) Forgive and Remember, Chicago and London, the University of Chicago Press.

152 liana Lowy Bury, M.R. (1986) 'Social constructivism and the development of medical sociology', Sociology of Health and Illness, 8,137-69. Caplan, A.L. (1986) 'Exemplary reasoning? A comment on theory structure in hiomedidne', Journal of Medicine and Philosophy, 11, 93-106. Coe, R.M. (1970) Sociology of Medicine. New York, St. Louis & St. Francisco: McGrawHill. Elkana, Y. (1986) 'Is there a distinction between external and internal sociology of science'. In R.S. Cohen and T. Schnelle (eds).. Cognition and Fact: Materials on Ludwik Fleck. Dordrecht: D. Reidel Publishing Company, 309-16. Figlio K. (1982) 'How does illness mediate social relations? Workmen's compensation and medico-legal practices 1890-1940s' in P. Wright and A. Treacher (eds) The Problem of Medical Knowledge. Edinburgh: Edinburgh University Press. Fleck, L. (1927) 'Somespecificfeaturesof the medical way of thinking', in R.S. Cohen and T. Schnelle (eds).. Cognition and Fact: Materials on Ludwik Fleck. Dordrecht: D. Reidel Publishing Company, 39-46. First published in 1927 (L. Fleck, O. niektorych swoistych cechach myslenia lekarskiego', j4rc/iv/MW Historji i Filozofji Medycyny oraz Historiji Nauk Przyrodniczych, 6, 55-64). Fleck, L. (1929) 'On the crisis of "reality"' in R.S. Cohen and T. Schnelle (eds).. Cognition and Fact: Materials on Ludwik Fleck. Dordrecht: D. Reidel Publishing Company, 47-58. First published in 1929 (Fleck, L. 'Zur Krise der "Wirkichkeit"', Naturwissenschaft, 17,425-30). Fleck, L. (1934) 'Jak powstal odczyn Bordet-Wassermana i jak w ogole powstaje odkrycie naukowe', ('How did the Bordet-Wasserman reacion originate, and how does a scientific discovery originate in general'), Polska Gazeta Lekarska, 10-11,1-14. Fleck, L. (1935a) Genesis and Development of a Scientific Fact,firstpublished by Benno Schwabe, Basel, 1935; English translation by Bardley F. and Trenn T.J., University of Chicago Press, 1979. Fleck, L. (1935b) 'Zur Frage der Grundlagen der medizinischen Erkentnis', Klinische Wochenschrlftl4,1255-1259; translated by Trenn T. and Bradley F. (1981), 7oMma/ of Medicine and Philosophy 6,237-56. Fleck, L. (1935c) 'Scientific observation and perception in general', in R.S. Cohen and T. Schnelle (eds).. Cognition and Fact: Materials on Ludwik Fleck, Dordrecht: D. Reidel Publishing Company, 59-78. First published in 1935 (Fleck, L. 'O obserwacji naukowej i o postrzeganiu w ogole' Przeglad Filozoficzny, 38,58-76). Fleck, L. (1936) 'The problem of epistemology' in R.S. Cohen and T. Schnelle (eds)., Cognition and Fact: Materials on Ludwik Fleck. Dordrecht: D. Reidel Publishing Company, 79-112. First published in 1936 (Fleck, L. 'Zagadnienie teorji poznawania' Przeglad Filozoficzny, 3-37). Fox, R.C. (1985) 'Reflections and opportunities in the sociology of medicine'. Journal of Health and Social Behaviour, 26,6-14. Freeman, H.E. Levine, S. Reeder, L.G. (eds.) (1972) Handbook of Medical Sociology. Engelwood Cliffs, New Jersey: Prentice-Hall Inc. 1972. Gabbay, J. (1982) 'Asthma attacked? Tactics for the reconstruction of a disease concept', in P. Wright and A. Trecher, The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh: Edinburgh University Press, 23-48. Giedymin, J. (1986) 'Polish philosophy in the Inter-War period and Ludwik Fleck's

Ludwik Fleck 153 theory of thought-styles and thought-collectives' in R.S. Cohen and T. Schnelle (eds).. Cognition and Fact: Materials on Ludwik Fleck., Dordrecht: D. Reidel Publishing Company, 179-216. Good, B.J. and Delvecchio-Good, M.J. (1981) 'The meaning of symptoms: a cultural hermaneutic model for clinical practice'. In Eisenberg L. and Kleiman A. (eds.) The Relevance of Social Science for Medicine, Dordrecht, D. Reidel Publishing Company. Gorvitz, S. and Maclntyre, A. (1976) 'Towards a theory of medical falliability'. Journal of Medicine and Philosophy, 1, 51-71. Harwood, J. (1986), 'Ludwik Fleck and the sociology of knowledge', Social Studies of Science, 16,173-87. d'Hautaud, A. and Field, M.G. (1984) 'The image of health: variations in perception by social class in French population'. Sociology of Health and Illness, 6(1), 30-60. Ingelby, D. (1982) 'The social construction of mental illness,' In The Problem of Medical Knowledge: Examining the Social Cortstruction of Medicine. Wright P. and Treacher A. (eds.), Edinburgh University Press. Kendall, P.L. and Selvin, H.C. (1966) 'Tendencies toward specialization in medical training'. In Scott W.R. and Volkart E.H. (eds.) Medical Care: Readings in the Sociology of Mediccd Institutions. New York and Sydney: John Willey and Sons Inc. Kendall, P.L. and Reader, G.G. (1972) 'Contribution of sociology to medicine'. In Freeman et al (eds.). Handbook of Medical Sociology. Engelwood Cliffs, New Jersey: Prentice Hall Inc. King, S.H. (1962) Perceptions of Illness and Medical Practice. New York: Russel Sage Foundation. Knorr, K. Krohn, R. and Whitely, T. (eds.) (1981) The Social Process of Scientific Investigation. Dordrecht: Reidel. Knorr, K. and Mulkay, M. (eds.) (1982) Science Observed. New Perspectives in the Sociology of Science. London: Sage. Kuhn, T.S. (1%2) The Structure of Scientific Revolutions. Chicago University Press. Kuhn, T.S. (1979) 'Foreword', in Fleck L. Genesis and Development ofa Scientific Fact, English translation by Bardley F. and Trenn T.J., Chicago and London: University of Chicago Press. Lipton, J.P. and Hershaft, A.M. (1985) 'On the widespread acceptance of dubious medical findings', JoMrna/ of Health and Social Behaviour, 26, 336-51. Loux, F. (1978) 'Sante et maladie dans Ies representations populaires francaises tranditionelles et modemes'. In Santi Medecine et Sociologie, Paris, CNRS, 311-5. Lovejoy, A. (1960) The Great Chain of Being: A Study ofthe History of an Idea. New York: Harper and Row (1st edition 1936). Matthews, M.J.J. (1983) 'The communciation process in clinical setting'. Social Science and Medicine, 17,1371-8. MauU, N. (1981) 'The practical science of medicine'. Journal of Medicine and Philosophy, 6,165-82. McCuUough, L.B. (1981) 'Thought-styles, diagnosis and concepts of disease: commentary on Ludwik F[eck', Journal of Medicine and Philosophy, 6,257-61. Mechanic, D. (1982) 'Social psychological factors affecting the presentation of body complaints'. New England Journal of Medicine, 286(21), 1132-9.

154 liana Lowy Metzger, H. (1933) 'L'historien des sciences doit-il se faire le contemporain des savants dont il parle?', Archion, 15, 34-44. Metzger, H. (1937) 'Le r61e des precurseurs dans revolution de la science', Thalis 4,199-209. Merton, R.K. Reader, G. and Kendall, P.L. (eds) (1957) The Student Physician. Cambridge, Harvard University Press. Morgan, D.L. and Spanish M.T. (1985) 'Social interactions and the cognitive organisation of health-relevant knowledge'. Sociology of Health and Ilness, 7(3), 342-74. Nicolson, M. and McLaughlin, C. (1987) 'Social constructionism and medical sociology: a reply to M.R. Bury', Sociology of Health and Illness, 9(2), 107-126. Panofsky, E. (1955) 'The history of art as humanistic discipline', (first published in German in 1940), In Panofsky, E. Meaning in Visual Arts. New York: Doubleday Anchor Books. Sadegh-Zadeh, K. (1981) 'World 5 and medical knowledge', Journal of Medicine and Philosophy, 6,263-70; Samora, J. Sanders, L. and Larson, R.F. (1966) 'Medical vocabulary knowledge among hospital patients'. In Scott W.R. and Volkart E.H. (eds.) Medical Care: Readings in the Sociology of Medical Institutions. New York and Sydney: John Willey and Sons Inc. Schnelle, T. (1986) 'Microbiology and philosophy of science, Lwow and the German holacoust: stations of life. Ludwik Fleck, 1896-1961', In R.S. Cohen and T. Schnelle (eds)., Cognition and Fact: Materials on Ludwik Fleck, Dordrecht: D. Reidel Publishing Company, 3-36. Shaffner, K.F. (1986) 'Exemplar reasoning about biological models and diseases: a relation between the philosophy of medicine and philosophy of science'. Journal of Medicine and Philosophy, 11, 63-80. Strong, P.M. (1984) 'Viewpoint: the academic encirclement of medicine?' Sociology of Health and Illness, 6, 339-358. Temkin, O. (1977) 'The double face of Janus', in Temkin, O. The Double Face of Janus and Other Essays in the History of Medicine. Baltimore: The Johns Hopkins University Press, 137-169. Toulmin, S. (1986) 'Ludwik Fleck and the historical interpretation of science'. In R.S. Cohen and T. Schnelle (eds)., Cognition and Fact-Materials on Ludwik Fleck. Dordrecht: D. Reidel Publishing Company, 267-86. Tuckett, D. A. and Williams, A.J. (1984) 'Approaches to the measurement of explanation and information giving in medical consultations. A review of empirical studies'. Social Science and Medicine, 18,571-80. Tuckett, D.A., Boulton, M. and Olson, C. (1985) 'A new approach to the measurement of patients' understanding of what they are told in medical consultations'. Journal of Health and Social Behaviour, 26,27-38. Wassermann, R. and Inui, T.S. (1983) 'Systematic analysis of clinician-patient interaction: a critique of recent approaches with suggestion of future research'. Medical Care, 21,279-85. Wolniewicz, B. (1986) 'Ludwik Fleck and Polish Philosophy' in R.S. Cohen and T. Schnelle (eds).. Cognition and Fact-Materials on Ludwik Fleck. Dordrecht: D. Reidel Publishing Company, 217-22. Wright P. and Treacher A. 'Introduction', in Wright P. and Treacher A. (eds.), (1982) The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh University Press, 1-22.

Ludwik Fleck 155 Yoxen, E. (1982) 'Constructing genetic diseases'. In The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Wright P. and Treacher A. (eds.), Edinburgh University Press. Zborowski, M. (1952), 'Cultural components in responses to pain', iourna/ of Social Issues, 8,(4), 16-30. 2tola, I. (1963) 'Problems of communication, diagnosis and patient care'. Journal of Medical Education, 38. 829-38.