Skills through History.

Few historians would deny that skills are at the heart of modern medicine. Yet skill can prove troublesome to define. The content of what counts as a medical skill ranges widely across different dimensions of the body and self, as through places, disciplines and phases of history. From the physician’s touch in physical examination to the discriminating eye of the histologist, from empathy in nursing to precision in surgery: all suppose and reproduce a skilled practitioner. Despite or perhaps because of their abundance, skills have appeared too easily as a self-evident feature of medical history. Their ubiquity and the wide spectrum of concepts they assimilate have obstructed efforts to historicise them, or to explore the wider implications of their transience. Impossible to deny and yet notoriously hard to define, skills in medical history are everywhere and nowhere at once, persistent through its sources and yet rare as organising principles of its scholarship. The object of this volume is to address that asymmetry, and begin unsettling the self-evidence of skills by drawing them into critical focus.

This brief introduction sets out to foreground existing work in the history of medical and scientific skill, and to emphasise the richness of the topic. Our claim, however, is not that skills have been absent in medical historiography. On the contrary, they arise again and again, and often in ways that are consistent with the perspective advocated here. Historians have asked how the evaluation of skills was closely bound up with professional aims, for instance, or how new diagnostic methods invented and relied on new skills. They have described how skills were transmitted through pedagogical practices and how medical specialisation was connected (or not) to the proliferation of medical skillsets. Despite these efforts, the category of skill itself is still easily taken for granted. A closer examination promises to cast light on the varied and refined practices that skills include, and to strengthen the connections of medical history to other fields, such as the history of observation, objectivity, emotions and the senses.

Although the focus of this special issue will be on the last two centuries, work on skill is of course not restricted to this period. Obvious fields for examining its history are surgery and anatomy, both of which underwent regime changes in the Middle Ages and early modern period. Discussions of skill have been shown to have played a major role when the adherence to textual authorities was loosened and skills travelled between artistic and scientific worlds, and when craft knowledge took on a new significance in scientific endeavours. The topic of skill has also been relevant to discussions of European medicine of the late eighteenth century, when diseases were classified on the subjective feelings of patients (their ‘symptoms’), and sorted into classes, orders, genera and species, in the manner of botanical classification. Thomas Sydenham, the English physician and father of classificatory medicine, noted his debt to the ancients for teaching skill in therapeutics. For him, the Hippocratic texts stressed the primacy of observation untinged by distorting hypotheses: the correct natural classification of disease demanded an astute observer armed with a lucid mind. Sydenham and others modelled their art of observation on the Hippocratic authority, but also on botany and painting. Hence in the classificatory tradition the faithful transcription of all minute elements of a disease should proceed ‘in imitation of the exquisite industry of those painters who represent in their portraits the smallest moles and the faintest spots.’

Historians found in the break from classificatory medicine an opportunity to show how through disciplined investigation skilled practitioners came to generate and stabilise new objects of medical inquiry and intervention. Michel Foucault’s famous concept of ‘the clinical gaze’ evoked this broader system of changes, and also the relevance of skills to medical history. When, in late 1816, René Laennec applied a rolled-up paper notebook to the chest of a patient, he conceived of a skilled means to access the internal phenomena of bodies, a technique crucial to the wider localisation of disease that continued throughout the nineteenth century. The clinical gaze he helped establish was that of a physician backed by an institution, enrolled in new orders of knowledge and discipline; it sought colour, depth and variation beyond horizontal taxonomies of eighteenth century, and strove to calculate the chances survival and suffering. Foucault’s The Birth of the Clinic captured the intrinsic interconnectedness between new ways of knowing (and skilled) subjects and the identity of disease, calling forth the provocative circularity between the skilled diagnostician and the pathological body, a mutually constitutive relation seized on by many medical historians and sociologists since Foucault.

To take just one example, in his study of microscopic anatomy in Edinburgh during the 1830s, Stephen Jacyna has described the debates surrounding the introduction of microscopes, showing how the development of the field of histology depended upon a disciplinary regulation of vision and its verbal expression. As Jacyna explains: ‘The acquisition of technical competences was the precondition for participation in a shared morality.’ Practitioners were both active, in that they prepared their own slides and made their own observations, but also ‘docile … in as much as strict control was exercised over what counted as a competent microscopic performance and what constituted a true observation’. The new microscopists learnt to see with what Jacyna called ‘a skilled eye’, regulated vision that combined technical competence with disciplined judgement. As in the case of diagnostic and therapeutic techniques, the trustworthiness of the microscope required a studied cultivation of the senses, and the development of a particular capacity for sound judgement. But the cultivation of a skilled experimenter was not the only solution to the emergent problems of vision during the nineteenth century. Skill proved to be historically interesting in other ways too, not least in connection to the assimilation of data in medical research. In their recent account of the history of objectivity, Lorraine Daston and Peter Galison have noted instances in which the skill of the knowledgeable observer threatened to corrupt neutral observation, in which skill posed an obstacle to successful experimentation. They cite the French physiologist Claude Bernard, who advocated the use of untrained assistants for the collection of experimental data in an attempt to co-opt the passive senses of an unbiased observer.

The examples of observation and diagnosis, and in particular the detection of new phenomena, lead into another dimension of the history of skill pertaining to more recent work on experimental replication. The ‘experimenter’s regress’, as the sociologist Harry Collins calls it, denotes a problem whereby experimenters’ knowledge of the existence of certain phenomena depends on the accuracy of an apparatus used for its detection. Since the only way to determine the effectiveness of the apparatus is through the detection (or not) of the phenomenon, scientists confront a circularity whereby the existence of a phenomenon is only ascertainable by an experimental apparatus whose status is in question. In such cases, the correctness of an experimental result and the associated claims about nature become entangled with claims about the credibility and skill of the experimenter. Such quandaries have been as real to medicine as to science – for instance, in the introduction of new diagnostic methods (such as the stethoscope in the nineteenth century, or X-rays in the early twentieth) where questions of a physicians’ skill played a decisive role in the adoption and spread of the new technologies.

These disputes raise further questions, such as what it is that allows or restricts a skilful performance, or, more profoundly, what phenomena the concept of ‘skill’ can legitimately include. In the history of science, a skilful performance has often been connected to particular affective regimes, typically involving self-control, emotional restraint and the tempering of passions. The history of medicine offers similar examples. At one extreme is the cultivated indifference of the modern physician, who wields disinterest in the face of adversity and human suffering, a detachment founded historically on a contrast between emotional excess, which is seen to interfere with skill, and emotional restraint, which enables it. In the domain of emotional restraint it is the surgeon who is undisputed master, as attested to in a wealth of historical and ethnographic studies that have scrutinised the evolution of surgical decorum. When in 1912 Sigmund Freud recommended ‘emotional coldness’ for physicians practising psychoanalysis, he too cited the example of the surgeon who ‘puts aside all his feeling, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skilfully as possible’. Yet at another extreme is the status of emotion itself – that is, emotionality as skill. In a recent essay, the historian Elizabeth Lunbeck has noted the controversial proposals of Heinz Kohut, the prominent psychoanalyst and champion of empathy in psychoanalytic practice, who in the mid-twentieth century called into question the received antagonism between skill and emotionality. Untroubled by its impressionistic burdens, Kohut presented empathy not only as a tool of empirical science but also as a psychoanalytic strategy vital for the apprehension of inner experience. Lunbeck notes that much of the sustained controversy around Kohut’s idea was skill’s nebulous content, and whether or not emotions could plausibly count as skilful. Historically speaking, the answer came back as a resounding ‘yes’ – and not just among psychoanalysts. The inventory of skilled emotions widened exponentially with the birth and growth of bioethics in the later twentieth century, whose proponents have posited roll-calls of emotional and moral skills in pursuit of improved medical practice.

The entanglement of skills and emotions of course pre-dates the rise of psychoanalysis or bioethics, and has a much older and well-documented association in the history of nursing. The title of the historian Susan Reverby’s monograph, Ordered to Care: The Dilemma of American Nursing, 1850–1945, captures a persistent tension in this history between the realms of spontaneity and passion on the one hand, and reason and control on the other. Noting Florence Nightingale’s definition of ‘character as skill’, Reverby examines the assertion that womanly attributes were a component of a nurse’s ability to provide care during the nineteenth century. The sentiment was evident in Nightingale’s missionary efforts to export her ideal of nursing to Australia, during which she specified class, gender and the moral authority of ladies as the major sources of ‘nursing’s power’ – a power that consisted in protecting the humanity of patients otherwise obscured by the therapeutic encounter. ‘[I]t is quite surprising how many men (some women do it too), practically behave as if the scientific end were the only one in view,’ Nightingale remarked in her Notes on Nursing, ‘as if the sick body were but a reservoir for stowing medicine into, and the surgical disease only a curious case the sufferer has made for the attendant’s special information.’ The skilled nurse and woman was the antidote to such reductionist indifference; she alone could confer the status of patient and raise pathology into dignified suffering.

Yet Nightingale’s positive appraisal of feminine virtues finds a counterpoint in debates about women’s access to medical education of the same period. As women struggled to gain entry to the medical schools of Europe and North America in the nineteenth and early twentieth centuries, prominent opponents claimed that since femininity was bound by nature to empathy and compassion, its bearers were singularly unfitted for the trials of medical life. Feminist scholars have exposed the gendering of skill in this period as a political and exclusionary device, a weapon raised against women’s access to medical education on the grounds of their ‘natural’ unsuitability. In both examples – skilled femininity as virtue and as vice – skill figures as an essential, inherent quality of a gendered self. Its naturalisation comes freighted with implications.

Such examples further raise the question of what skill in fact is – if not a natural, innate quality of people, what kind of knowledge does skill represent? It is in response to this type of question that sociologists and historians began exploring the category of ‘tacit knowledge’ during the late 1970s and 1980s. A younger cousin to Gilbert Ryle’s distinction of ‘knowing how’ and ‘knowing that’ (itself derived from phenomenological roots), the distinction between explicit and tacit knowledge was first explored by the philosopher Michael Polanyi, and became of enduring inspiration for scholars of a later generation committed to the descriptive exploration of scientific, and later medical practices. Despite varying definitions, the tacit dimension became of indisputable heuristic value for the field of science studies in emphasising the face-to-face character of scientific work, and in dissipating a model of science as rule-bound and algorithmic. Medical historians borrowed the concept to similar ends, emphasising, for example, the embodied skills of surgeons, acquired through active and corporeal engagement rather than through explicit instruction.

Yet despite the remarkable payoffs of the tacit dimension, some authors have warned of the essentialist pitfalls in the liberal use of an analyst’s category, pointing out that tacit knowledge can be made explicit, or insisting that historians must contextualise actors’ use of the concept, and pay attention to actors’ vocabularies of skill, knowledge and learning. Polanyi’s formulation was notably saturated in politics from the start, asserting the immunity of scientific research to external planning. Likewise, embedded in the recent efforts by Harry Collins and others to clarify tacit knowledge are normative questions of expertise in science and scientific medicine: who should be included as contributory experts and who not, by whose authority or on what grounds? Whatever the value of the tacit dimension in casting a light on science as a cultural activity, the history of the term itself demonstrates what can be at stake when skills and knowledge are scrutinised and divided.

Similar political stakes are evident in the long-standing debates over the status of medicine as an ‘art’ or ‘science’. Making medicine scientific has been an often-used and successful strategy for increasing the influence and autonomy of the medical profession, and also for improving its practices. One means for turning medicine into a science was basing medical practice on the natural laws of body function determined by experimental science. This was Claude Bernard’s programme of ‘experimental medicine’ of the nineteenth century, which looked to the laboratory to lend credence to the clinic. In the second half of the twentieth century, medical reformers went further and re-described the entirety of medical practice as scientific – ‘every bit as scientific as the research laboratory’ – predicating their claims on the increasing standardisation of medical skills. Echoing the logic of experimental replication, they contended that the perfect reproducibility of therapeutic measures entailed the strict standardisation of every step of the therapeutic procedure. Yet such strategies did not go unchallenged. Opponents to standardisation feared that an exaggerated focus on science would undermine their professional autonomy in patient care, and presented medical practice as an inscrutable art, requiring diligence, experience and cultivated good judgement. They argued that standardisation would reduce medical treatment to mindless routine, performed by ‘unthinking physicians’. Along these lines, Christopher Lawrence has shown how during the nineteenth century elite London physicians raised criticisms against the swelling tide of scientific medicine threatening to unhinge their claims to clinical autonomy. These physicians espoused the virtues of the cultivated gentleman, criticising undue dependence on new medical technologies and the growth of specialisation. For them the clinical art was a holistic, ineffable form of knowledge based on a broad education in the classics and long years of clinical experience, irreducible to a formalised body of information bound by precise rules. Echoing the prominent anatomist and surgeon William Bowman, Lawrence proposed the term incommunicable knowledge, ‘an epistemology of individual experience which, by definition, defied analysis’, and which assured the protection of clinical art from the rising frontier of applied science, as well as from the pedagogical claims of a new generation of scientific teachers. The trenchant defence of generalism in clinical practice – and later of ‘holism’ – asserted the insufficiency of technical skills for sound clinical practice, defined as something beyond the mere functionality of a skilled executor.

Typically, characterisations of medicine as an art or a science do not represent realistic descriptions of attainable goals but offer, as Warwick Anderson has emphasised, ‘versatile discursive resources and strategies’ for the pursuit or maintenance of professional hierarchies, authority and autonomy. Conceived of as an art, medicine emphasises personal authority. According to this model, the transmission of skill requires apprenticeship, spectatorship, and, as Michael Polanyi explained, submission to authority: ‘You follow your master because you trust his manner of doing things even when you cannot analyse and account in detail for its effectiveness. … These hidden rules can be assimilated only by a person who surrenders himself to that extent uncritically to the imitation of another.’ By contrast, the understanding of medicine as a science can support (among other things) a quite different, avowedly meritocratic epistemology: clinical skills become generally attainable; anyone adhering to the rules can achieve good results. The ideal of clinical science, Deborah Gordon writes, ‘is characteristically explicit, universal, abstract and public’; it subordinates social privilege and upholds the accessibility of expertise.

If such strict divisions are shown easily by historians to be crude and simplistic, they have nonetheless been persistent and consequential features in the rise of scientific medicine. A profound belief in the virtues of science was a central plank in early twentieth century doctrines of ‘scientific management’, developed by, among others, the American engineer, Frederick Winslow Taylor, who from the 1890s sought to reorganise labour processes according to rigidly scientific principles. In Taylor’s thinking, skills could be measured, timed, quantified, and disassembled into elementary units, and then transferred to unskilled workers. Health care seemed to be an especially ripe candidate for such reform strategies. Between 1900 and 1920, tools from the world of business were imported to hospitals, newly conceived as ‘workshops for physicians’ or ‘health factories’, while surgery, considered a species of manual labour, was amenable to the time-and-motion analysis of the engineer Frank Gilbreth, an advocate of scientific management who famously rejected any qualitative difference between motions across practical domains. The ramifications of this levelling epistemology were clear to such reformers as the Boston surgeon Ernest Amory Codman, who wished to promote objective criteria in health care, and to the orthopaedic surgeon Robert Jones, said to have ‘never wasted a motion’, who was responsible for reorganising and standardising orthopaedic care in Britain before and during the First World War. According to the historian Roger Cooter, Jones became a leading figure for a whole cohort of British surgeons committed to technical expertise, who campaigned for the adjudication of practitioners on grounds of efficiency and productivity. From 1914, the Great War provided further occasion for introducing modern management techniques into military health care, both in British military medicine, for example, and also in Austria, where historians have described intense efforts at mobilising medical resources and economising manpower through the standardisation of medical practices.

These are just some examples of how historians have approached the topic of skills in medical history. As they indicate skills’ contingent status across time and through disciplines, they point further to the potentials of a history of skill, and suggest ties to related fields of inquiry such as the histories of objectivity and emotionality, the body and its senses.

Historicising Skills

The essays of this special issue comprise a selective collection aimed at establishing the thematic relevance of skills to history. In different ways, the authors examine how pathologists, bacteriologists, surgeons, nurses, chemists and genetic scientists of the nineteenth and early twentieth centuries confronted the question of skill across a range of contexts. They look at who claimed authority to participate in those struggles, and what was at stake in the determination, ascription, demonstration or denial of particular skillsets. The historian David Kaiser has noted through his reflections on the history of pedagogy, that within a given scientific field or specialty, ‘what counts as “appropriate skills”, always reflects active decisions (and often fraught controversy and bitter negotiations) in given contexts, and show[s] telling variation across time and space’. That variation is a starting point for this special issue. In exploring it further, we want to pursue the following kinds of question: When does skill become a salient or urgent focus for debate in medicine? How are skills defined and by what means? To whom or to what can skills be attributed or transferred? In what ways and in what contexts have skills been considered important, and who can claim the authority to define them? Is the presence of skill always considered a good thing, and, if not, on what grounds can a skilled activity be bad?

We are not to the first to raise such questions. Besides the work already noted, for other fields in history the definition of skill has been a central if not defining focus for analysis. Over the last four decades, labour historians have moved furthest in providing a critical history of skills, and have shown how such histories can proffer rich results. Much of this work has developed in response to Harry Braverman’s widely influential study of 1974, Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century, a seminal account of occupational changes to the American workforce during the early twentieth century. Braverman, a factory worker turned Marxist historian, had become increasingly frustrated with the abstractions of his sociological peers, and sought an empirical alternative to the analysis of labour. Based on the study of occupational trends in the American workforce, he described a systematic process of ‘deskilling’: the increasing division of holistic craft traditions into atomised, narrowly conceived, and supposedly mindless tasks, and the gradual replacement of skilled activities by automation and machinery.

Labor and Monopoly Capital prompted a stream of critical debate, much of which focused on Braverman’s important (though in fact not central) thesis of deskilling. Among the most interesting critiques were those which queried his definition of skill, and which doubted whether deskilling was truly a historical fact or merely an artefact of Braverman’s own assumptions about the nature of skill. Central to this strand of critique was what has been called a ‘strong current of constructionism’, an approach to treating skills not as natural givens but as historically situated and therefore transient concepts. The recognition that ‘many … skill distinctions are … determined socially and historically’, raised the question of who had hitherto defined skilled labour and what ends those definitions achieved. Feminist labour historians, for instance, began querying the political dynamics of skill, presenting it as a mechanism for imposing and sustaining gendered divisions of labour in nineteenth-century industries. Through case studies that traced the political and economic uses of notions of skill, they were able to show convincingly that ‘[f]ar from being an objective economic fact, skill is often an ideological category imposed on certain types of work by virtue of the sex and power of the workers who perform it’. Common to such studies was a sustained interest in unpicking the consequences of the languages of skill. The deskilling debate, as well as the various processes it referred to – the automation of manual work, the specialisation of tasks and increasing divisions of labour, the use of efficiency as a gold standard, the compulsions of capital logic – can be seen as part of a critical expansion of what was understood as skill in the conceptual sense. It becomes clear in retrospect that the discussions on deskilling were as much about constructing the concept of skill as about lamenting its decline among labourers of late capitalism. Skills were not merely the object of critical investigation, they were also its product.

Focused on Anglo-American and European contexts of the recent past, the papers collected here are similarly committed to exploring the historical contingency of skill. In doing so, they seek to challenge some engrained assumptions common to its history, such as the belief that skill is an obviously desirable quality of workers. In her essay on the first generation of American neurosurgeons, Delia Gavrus describes the establishment of a specific ethical regime of professional practice, which entailed a tension between advanced levels of surgical skill and the moral integrity and trustworthiness of practitioners. The most dangerous surgeons, the new neurosurgeons contended, were those with skills in abundance, the maverick showmen whose excessive competence and theatrical tendencies imperilled both patient and specialty. Gavrus pays particular attention to the establishment of a distinctive social space, ‘the specialist society’, in which skills could be determined and evaluated, and by which entry into the elite world of neurosurgery could be regulated.

In his account of skill in modern surgery, Thomas Schlich likewise considers variations in meanings of surgical skill across the nineteenth and twentieth centuries, noting their entanglements with aesthetic categories of elegance, artistry and surgical style, but also with ethical standards of the time. He uses the notion of performance to look at changing evaluations of surgical skill and how they were predicated on the technical, professional, and moral contexts in which surgical work took place. The meaning of desirable skill in surgery underwent significant changes over the course of the nineteenth and early twentieth centuries, complicating any simplistic assumptions about the dependence of surgical work on manual skill.

Surgery is one example of how claims to skill can define boundaries between expert groups, thus steering and shaping professional identities. In her essay on the establishment of the specialty of neuropathology in postwar England, Kathryn Schoefert shows how another professional identity was associated with a particular definition of skill. The new specialty of neuropathology incorporated elements of microscopy, and was perched between neurology, psychiatry and neurosurgery. Yet as Schoefert demonstrates, the means available to neuropathologists for their self-definition were constrained by the institutional forces of the British National Health Service, as by the competing claims of neighbouring disciplines. Schoefert’s analysis of a precarious medical specialty resonates not only with sociological accounts of boundary work, which stress the instrumental distinctions deployed by scientists to demarcate their practices, but also with studies that analyse how attributions of skill can serve specific institutional goals and interests.

The relationship of skills to standardisation is the theme of Nicholas Whitfield’s analysis of the Carrel–Dakin wound treatment of the Great War, which he considers in relation to currents of standardisation, scientific medicine and theories of scientific management. Whitfield describes how, according to contemporary estimations, the Carrel–Dakin method increased rather than diminished demands on surgical skill, and that contemporary debates about antiseptic wound treatment opened up a critical space for considering the nature of skill as a defining feature of surgical practice. Whitfield contributes to accounts of standardisation in medical history by splitting them away from narratives of deskilling. The standardisation of wound treatment was not a moment at which skills vanished in the shadow of modernity and scientific medicine, but a point at which skill was figuratively expanded and drawn to the heart of surgical practice.

Shifting from professions to pathologies, Susan Lamb’s paper investigates skill in early twentieth-century Anglo-American psychiatry. Her focus is Adolf Meyer, the influential American psychiatrist, who in the decades prior to the First World War advocated a new set of clinical skills for what he termed ‘the new psychiatry’. Looking in detail at Meyer’s conception of ‘psychobiology’, a biological theory of mind and mental disorders, and at clinical practices and teaching at Johns Hopkins between 1913 and 1917, Lamb discusses how social and interpersonal skills became a vital means for Meyer to access, collect and analyse the ephemeral data of patients’ social adaptations. Arguing that the social skills of the new psychiatrist were essential for constituting and treating patients according to the psychobiological approach, Lamb demonstrates the mutuality and co-dependence of clinical skills and pathologies.

In an essay that focuses on a controversy in the recent history of behaviour genetics, Nicole Nelson confronts the topic of experimental practice, and, in particular, the experimenter’s regress. Her empirical focus is on new techniques for manipulating mouse DNA, developed in the 1990s, that allowed researchers to ‘knock out’ specific genes in mice in order to observe the behavioural effects. How to deploy these techniques became deeply controversial, and Nelson examines key methodological debates between a predominantly North American group of molecular biologists and animal behaviourists. She not only considers the overlaps of particular experimental facts about knock-out genes with judgements about who and what was generating them, but also shows how more substantive ideas of experimental skill were interwoven with the epistemologies of different knowledge-producing communities.

With their common orientation, these essays intend to expand and reposition skill as a fruitful focus for historical analysis and to highlight a broad range of avenues for future scholarship. Skills have a history – a long one – and though it is much wider than the present special issue could possibly encompass, we hope that the consciously historicist stance advocated here – skills through history – will challenge their presentation as stable qualities of medical practice, and cast further light on neighbouring areas of medical history whose tangled stories they intersect.