"The Emergence of the Modern Mode of Medical Production," Humanity and Society, Vol. 9, No. 4 (November 1985), pp. 371-387 by Gordon Welty Wright State University Dayton, OH 45435 USA [//371] Reflexive Statement The impetus to this study came about a dozen years ago when I had a series of abscesses in my left hand. During one of the operations I underwent, the local anaesthesia wasn't effective. The nurse gave me a rolled gauze bandage to bite on, and they proceeded. Afterwards I asked the surgeon what it was like before anaesthesia. He replied "This is pretty much the way it was." So I was motivated to study the development of surgical anaesthesia. I was dissatisfied, however, when I looked into the social scientific literature, The opportunity for this study presented itself a few years later, when I lived in Philadelphia, and had access to the excellent historical holdings of the libraries of the College of Surgeons and the University of Pennsylvania. But my dissertation -- painful in a different way -- and other projects have delayed the completion of this research until now.

Introduction Health care in the United States has become a topic of increasing controversy in recent years. The enormous increase in the cost of health care has fueled the controversy, but issues more profound than those of cost are involved. The relative constancy of the adult life span during the last half of the Twentieth Century has called into question the wisdom of vast aggregate expenditures on health-related research, or at least the orientation of that research. Moreover, the particular critiques of health care in the United States by members of the medical profession (e.g. Mendelson, 1979), by traditional critics (such as the Health Policy Advisory Council; cf. Ehrenreich and Ehrenreich, 1970), as well as by 'competitors' (such as homeopaths; cf. Coulter, 1973, esp. Vol. 3), provide detailed evidence that the medical-health industry, as currently constituted and directed, is either unable or unwilling to serve the health care needs of the vast majority of Americans./1/ Dr. Robert Mendelson's reference to himself as a "medical heretic" is significant; in the scientific study of sacred and secular ideology the heretic is the opponent of the orthodox on existing terrain of contention and would replace the orthodox within the dominant social form. Another instance in the medical-health industry is the homeopath who would replace the presently hegemonic allopath. Thus heresy is to be understood as [371/372] social change by substitution. Heretic and orthodox are to be contrasted to the revolutionary who seeks to sublate this contention and to transcend this terrain by carrying the struggle to a broader terrain or to a higher level of emancipation. Thus revolution is to be understood as social change by structural transformation. This can be formulated as a question. Can the problems of health care in the United States be resolved within the existing political and economic context, or does the resolution of health care problems implicate structural and totalistic social change? In attempting to answer this question, I will outline the nature of the modern mode of medical production and will sketch the historical lines of its development during the Nineteenth Century. This mode of medical production is the internal relations of today's medical-health industry if we examine the organic structure beneath the myriad of institutional forms, medical-surgical practices, and particular personalities which make up the everyday world of health care in the United States. Only by such a study of the underlying mode of medical production can we address our question and come to apprehend the possibilities of long-term social change in the medical-health industry because such possibilities are constrained if not determined by that modality. This essay has four parts. First, we will engage in a brief analytic sketch of the nature of modes of medical production. This discussion is based on the Marxian categories of the reproductive labor process. Next, we will consider the development of one crucial constituent of the modern mode of medical production, that of surgical anaesthesia during the first half of the Nineteenth Century. Then, we will consider the development of another constituent of the modern mode, antiseptic surgery, during the same century. Finally, we will indicate how these elements were constituted into the modern mode of medical production, as this mode was itself integrated into the capitalist social formation in its highest stage. Section I: The Analytics of the Modes of Medical Production. Marx distinguished productive labor from reproductive (or "unproductive") labor. The former labor produces surplus values while the latter does not, rather reproducing the everyday world which is necessary to the production of surplus value (Marx, 1963:392-3). It is of interest to us that reproductive activities are either coextensive with or specializations of the domestic or natural economy (cf. Welty, 1978:9). Medical services are explicitly mentioned by Marx as an instance of reproductive labor, as the "cost of repairs for labor-power" (Marx, 1963:163). Genetically, the shaman was the initial specialization to emerge in the segmentary society, the first 'profession' to develop out of the natural economy. Thus both analytically and genetically our discussion of the development of the modern mode of medical production and surgery can for the time set aside the issue of the appropriation and distribution of surplus value and concentrate instead on the process of reproduction. Marx considered production in general as a complex totality, an ensemble of laborer or the subject of labor, the object of labor, the instruments of labor, and the appropriator of surplus labor-product in the an antagonistic social order (Marx, 1954:178; cf also Welty, 1983:289-290). Moreover, for Marx [re]production (production in the antagonistic social order sans appropriator) is historically conditioned by "a definite stage of social development," [372/373] that is development of the forms of social antagonism (Marx, 1971:18; Marx and Engels, 1975, Vol. 6:515). Since we have set aside the issue of appropriation, only the first three of the elements of the ensemble listed are germane to our present discussion. They comprise the moments of the process of the reproductive labor process which is involved in the provision of services, medical-health and surgical services in particular (cf. Fichtenbaum, 1982/83:42). Following Marx, this can be characterized as a labor process where "man's activity, with the help of the instruments of labor, effects an alteration, designed from the commencement, in the material worked upon. The process disappears in the [service]. . ." (Marx, 1954:180). That man's activity (in this instance the physician's or surgeon's provision of services) is [re]productive labor is straightforward, except that the physician or surgeon may be more or less skilled, better or worse educated, as we have occasion to note below. Included among instruments of labor are "all such objects necessary for carrying on the labor process." Among these objects is the tool, "a thing, or complex of things, which the laborer interposes between himself and the object [Gegenstand] of his labor" (Marx, 1954:179-180). Among these were also the so-called auxiliary materials, which are entirely consumed in the labor process (Marx, 1962, Vol. 2:159-62). The scalpel, for instance, is a tool, and both the ether of anaesthesia and the carbolic acid of antisepsis are auxiliary materials. In a striking passage on the instruments of labor, Marx states the "laborer makes use of the mechanical, physical and chemical properties of some substances in order to make other substances subservient to his aims" (Marx, 1954:179). In terms of Marx's conception of the object of labor wherein the labor of the physician or the surgeon is materialized (in the present instance that is the patient), it follows that this patient is included with the instruments of labor in the means of [re]production (Marx, 1954:179). The means of reproduction, in contrast to the laborer, are located in the realm of Nature and the interrelationships of these means are those of physical (or natural) laws (Marx, 1954:177-8). Given these natural laws, a limited number of specific ensembles of instruments of production are possible to achieve some planned transformation of the object of labor. Marx comments of instruments of labor and the development of forms of human labor that the instruments are "indicators of the social conditions under which that labor is carried on" (Marx, 1954:180). Now indices of social conditions should not be technologistically confused with social relations themselves. As we will see, it is not possible to take technological development (e.g. the invention of aseptic surgical practices) as anything but an index of social change, since technological developments prove to be most necessary but not sufficient conditions for social change. Scalpel, bone-saw, boiling water, gauze, etc. constituted the instruments of labor or pre-modern medical-surgical practice; in conjunction with the screaming, physically constrained patient these instruments made up the pre-modern means of surgical [re]production (cf. also Fichtenbaum, 1982/83:33). The surgeon's labor was only formally capitalistic; it was in fact a form of petty commodity production (Marx, 54:508ff.). Toward the close of the 19th century the same tools plus anaesthetics and antiseptics [373/374] as auxiliary materials constituted the quite different instruments of labor of the modern mode of medical production; in conjunction with the "patient etherized upon a table," these instruments made up crucial elements of the modern means of medical production and of surgical reproduction (Friedson, 1970:48). This labor has increasingly proved to be capitalistic; the physician and surgeon are becoming (very well rewarded) members of the working class, employees of the medical-health institution. At present, about 50 percent of physicians are salaried employees rather than the traditional entrepreneurial professionals (Kahn and Orris, 1982). Conversely, the remainder of physicians are becoming capitalists themselves as they come to employ receptionists, nurses, assistants, paramedics, etc. (cf. Fichtenbaum, 1982/83: 35-39). An understanding of the social change from the pre-modern to the modern mode of medical production may promote our understanding of the possibilities for long-term social change to alleviate the inadequacies of health care in the United States. Let us consider the organic structure of the modern mode of medical production by examining the development of one of its constituents, surgical anaesthesia. Section II: The Development of Surgical Anaesthesia A key element in the emergence of modern medicine was the Nineteenth Century development of surgical anaesthesia, a widely recognized development which warrants study in its own right. Nonetheless, the various historical accounts of this development tend to be either superficial or mutually contradictory. We will begin with the clearest examples of these, the culturological accounts. Nicholas Greene, for instance, recently held that a cultural "climate" of "humanitarianism" was necessary for the development of anaesthesia (1971:515). Presumably the medical-surgical inventors and disseminators are responding to human suffering and the need to alleviate that suffering. Virginia Thatcher, by contrast, argues for the primacy of "incentives for the ruthless acquisition of wealth and fame" (1953:7; see however Garrison, 1929:506). On this account, the inventors and disseminators are simply types of entrepreneurs. Both these accounts are superficial since they overlook the specifically cognitive and scientific value to which inventors and disseminators respond (cf. Fleck, 1979:38ff). Moreover, these accounts are mutually contradictory. A well-known tradition of contemporary sociological thought associated with Talcott Parsons (1954) was devoted to reconciling just such discordant culturological themes. This tradition stressed the necessity of a systematic conceptual scheme for such efforts at value reconciliation, and it has become evident in the past decade that this tradition was unable to develop, let alone maintain, such a conceptual scheme. To the extent that discordant values reflect more profound social antagonisms, the reconciliation of these values will be chimerical. Consider further examples. Greene, again, argues abstractly for the necessity of the development of surgical anaesthesia. "The discovery of anaesthesia was essentially impossible before the end of the Eighteenth Century, but by the early part of the Nineteenth Century men's affairs had progressed to such a level that it was almost inevitable that anaesthesia [374/375] would be discovered prior to about 1850" (1971:518; see also Duncum, 1947:9). The superficiality of these accounts, their lack of historical concreteness leads again to mutually contradictory explanations. Howard Raper, for instance, promotes the thesis of indeterminacy. "The casual, even accidental character of many great discoveries is well known...... Discoveries such as that of Wells [of anaesthesia] are above all else, mental triumphs -- sudden decisive victories for the brain of man" (1945:72-3). Raper's argument is suggestive of a psychologistic account of the development of surgical anaesthesia; we will shortly turn to these accounts. It seems the particular culturological discord between Greene and the 'necessitarians' and Raper and the 'indeterminists' turns on the methodological confusion of the ex post "assertability" of the use of surgical anaesthesia on March 30, 1842 with the ex ante "inferability" of that event (Grünbaum, 1964:293; Engels, 1964:221-4). The 'necessitarians' are unable to infer the event; the 'indeterminists' simply eschew any attempt at inference, even though this is a crucial element of scientific understanding. Incidentally, Raper's reference to Dr. Horace Wells is significant; he was one protagonist in the priority fight which raged over the development of surgical anaesthesia. The methodological problems of necessity and indeterminism, assertability and inferability were abetted by the inordinate concern over assertability which is occasioned by a protracted priority fight. Thus, the culturological approach to the explanation of the development of surgical anaesthesia seems to have limited merit, since its abstract or merely 'notational' ideas do not facilitate epistemic control over the interjection into the study of extraneous factors (such as a priority fight), and they do not permit the resolution of empirical incongruities either. Let us turn then from the culturological to the psychological accounts. In his essay on Metabletics, M. Jacobs has argued that anaesthesia came into use because "man's disconnectedness from matter, from labor, man's general loneliness, increased so much" that pain could not be endured (1969:635). This change occurred, for Jacobs, during the Industrial Revolution. Here we find the explicit introduction of a causal factor of systematic and historical import, viz industrialization. At first glance this reminds us of Marx's description of the "utter indifference, alienation, and expropriation" of the wage-laborer under the regime of capital (Marx, 1975, Vol. 3:84). But the resonance is deceptive. The Marxian concept of alienation is first and foremost that of a structural characteristic of the antagonistic social order (cf. Séve, 1978: Ch. II). Marx is quite unequivocal as he insists of alienation that "this twisting and inversion is real, not a supposed one existing merely in the imagination of the workers and the capitalist" (Marx, 1971:150-1). Thus the fashionable equation of alienation with a social psychological state of consciousness -- with neurosis, as promoted by Melvin Seeman (1959) and others -- cannot be sustained on Marxian grounds and has frequently been charged with superficiality (cf. Schacht, 1970:Ch. 5). Jacobs argues in social psychological rather than structural terms when accounting for development of anaesthesia. He supposes that historical change (the Industrial Revolution) directly bears on psychological states (as in the tolerance of pain) which causes anaesthesia to be used. Such an argument is psychologism, reductionism. [375/376] The anaesthetic properties of nitrous oxide were discovered by the eminent British natural scientist, Sir Humphrey Davy, prior to 1800. Davy suggested at that time that "it may probably be used with advantage in surgical operations" and a number of English physicians such as the esteemed Dr. Beddoes were involved in Davy's experiments (Davy, 1839, Vol. 3:329). Yet the first application of anaesthesia in surgery waited for the Georgia physician, Dr. Crawford Long, in 1842 (Long, 1849:709; Taylor, 1928:98).

Jacobs asks why the use of anaesthesia was delayed for over forty years. He responds as follows. He identifies the "alienation" of man, caused by the Industrial Revolution, with an increase of "social" pain and finally with a decreasing resistance to physical pain. Again the psychologism, the supposition of a direct relationship between historical change and states of consciousness. Jacobs goes on (1969:635) to suggest that "people in former times had a capacity to stand pain which seems nowadays impossible." [It is illuminating to contrast to this Joan Robinson's claim that "there is no reason to suppose that the natural passions were changed in the nineteenth century" (1970:67).] Jacob's monistic conception of resistance to pain should be noted; all the research on response to pain suggests to the contrary that there is a myriad of social factors which relate to variations in response to pain (cf. Welty, 1971:57). Finally, regarding the forty- year "delay" in the use of anaesthesia, Jacobs concludes that "the only reason must have been because there was no need" (1969:635). Hence he attributes the development of surgical anaesthesia to a shift in mentalistic parameters rather than to social conditions. In sum, the psychological approach to the explanation of the development of anaesthesia has limited merit as well, since its speculative conceptions do not apprehend diversity, and tend to misconstrue the dialectical 'unity of difference' (e.g. social factors which mediate pain response) as an abstract identity ("need"). It is striking how little attention has been given by historians to this forty-year span between the discovery and application of the anaesthetic properties of gases in surgery. In the middle of that period, an Englishman named Henry Hickman tried unsuccessfully to publicize his experiments with anaesthetic surgery (Boland, 1950:10-11; Bankoff, 1946:132-4). This is suggestive that the development of anaesthesia, like most of the developments in the cultural sphere, was an uneven one (Welty, 1981:7). Symptomatic of the lack of concern for the actual historical circumstances of the development of anaesthesia is Thomas Keys' rather diffuse suggestion that Hickman failed to influence surgeons in England or elsewhere "because of the many prejudices of the era" (Keys, 1945:19; see also Thatcher, 1953:5). Historically, it is well known that there is a period of time between the discovery or invention and the practical application of a cultural artifact such as surgical anaesthesia. It is also well known that this period of time is historically conditioned; it has been diminishing over the past few centuries. In particular, the period for a discovery in 1800 to have practical application was in the neighborhood of forty years. While a description provided by a curve fitted to a statistical summary of phenomena should not be confused with an explanation of those phenomena, it should be clear that the rate of development of anaesthesia is not at all [376/377] extraordinary when compared to the rates of development of other cultural artifacts. The notion of "cultural lag" is frequently invoked to explain the curve relating inventions or discoveries to their practical applications. On the one hand such usage scarcely does justice to the work of Wm. Ogburn (1933), who originated the notion, since the vulgar usage ignores the precondition of the "cultural base" which must be considered in its institutional concreteness in order to ground the cultural lag. Only with an explicit and systematic account of social factors can such a consideration proceed. On the other hand, the cultural base was primarily technological for Ogburn, so that religion and other cultural factors must still be introduced into the discussion of cultural lag. A useful itemization of the properly cultural factors relating to the development of surgical anaesthesia has been given by Greene. He notes that secularization -- specifically "humanitarianism" and "democratization" -- were "prerequisites." Quite rightly he emphasizes that religious teaching about the necessity of pain retarded the development of anaesthesia (1971:516-7; also Boland, 1950:9). Philosophical conceptions can also be mentioned, such as the high regard for the 'stoic' reaction to pain. The secularization that accompanied the Enlightenment subjected these religious teachings to scathing criticism, culminating in the philosophical ruminations of Jeremy Bentham (1960:303-4) and the adoption of the 'humane' guillotine (cf. Hampson, 1963:118-9). The alternative conceptions, such as those held by the Utilitarians or the Sentimental School, were only coming to fruition at the end of the Eighteenth Century (cf. A. Smith, 1853), and the religious conceptions had some viability well into the Nineteenth Century (cf. Durkheim, 1973:55-56). As an instance of the analysis of the cultural base which might do justice to Ogburn's conception, there appear to have been purely technical barriers of instrumentation in the way of the widespread use of anaesthesia. In a letter dated March 1, 1852 to Dr. William Morton, then Surgeon General Thomas Lawson commented on the extent of the use of surgical anaesthesia during the Mexican War of 1849 by suggesting that problems of administering gas had occurred, which inhibited its general employment (Congressional Globe, August 28, 1952, Vol. 25:1099). It will be recalled that anaesthesia was administered in these early years by placing a piece of gauze over the patient's nose and mouth and allowing drops of liquid ether or chloroform to drip onto the gauze and evaporate into a mixture of gas and air which the patient inhaled, the so- called "rag and bottle" technique (Robinson, 1946:259ff). This instrument of labor was not well suited for the tent hospitals of the battlefields. Instrumentation is a typical problem in the dissemination of medical-surgical innovations. Early asepsis consisted in covering the entire wound area with a solution of carbolic acid (Lister, 1867:246). The rise of antiseptic, as contrasted with aseptic surgery, entailed an instrument change. Likewise, the medical use of morphine as an analgesic awaited the development of the hypodermic needle, another case of instrumentation affecting medical practice (Singer, 1928:329). [377/378] In the case of anaesthesia, the instrumentation problem had side effects which compounded the issue of acceptability of anaesthesia in surgery. The surgeon was liable to anaesthetize himself with the early anaesthesiological techniques, as he as well as the patient inhaled the evaporating ether. For instance, the noted Philadelphia surgeon H. H. Smith comments in his 1852 treatise on surgery "I have myself been affected by extreme lassitude from breathing the atmosphere . . . during a prolonged etherization" (1852:28). Let us turn now to the domain of social relations, properly speaking. The layman has harbored an assumption about the invariance of medical school education. As a component of the ideology of professionalism, this belief warrants the popular assumption of both the standardization and the adequacy of medical treatment. This hypostatization of what in fact is a variable set of institutions and social structures has been undermined seriously by the work of Eliot Freidson (1970 and 1976), Burkart Holzner (1968:91-3), and other sociologists of knowledge and expertise (cf. also Fleck, 1979). Their work allows us to hypothesize that the ignorance of the physician, due in good part to his medical education, was a reason why anaesthetics were not employed in medical practice and surgery at the beginning of the Nineteenth Century. Evidence for this hypothesis is provided by the forum of the priority fight mentioned before. This attempt to establish precedence is thus not to be taken as anything more than the occasion which manifests adumbrations of the surgical use of anaesthesia. The priority battle ensued when the dentist Morton proclaimed his discovery of Letheon in 1846. The struggle eventually spilled over into the United States Congress. There Senator Truman Smith stated that "For the last fifty years, physicians have been administering nitrous oxide gas, sulphuric ether, and chloroform; but they had not found out that under the effect of these substances the knife could be applied to the system without producing pain" (cf. Congressional Globe, 1852, Vol. 25:1093). During the Senate debate, in the course of a brief history of the use of anaesthesia, Senator Isaac Walker remarked that the closest anyone had come to recognizing the merit of these anaesthetics in medical-surgical practice was Nysten, who in the 1815 Directory of Medical Sciences discussed ether as "mitigating pains of colic" (Congressional Globe, 1852, Vol. 25:1096). Chapman (1831) illustrated the state of knowledge when he stated "it is difficult to imagine a case in which [ether] should supersede wine." The main use of the anaesthetic gases prior to the 1840's seems to have been in medical school pranks and consciousness-altering experiments by the likes of S. T. Coleridge. This ignorance of the surgical anaesthetic merits of ether was characteristic of medical school education and was reproduced in medical practice. Not only were physicians ignorant of the merits of anaesthesia for surgery, but they were apprehensive of the possibly injurious side effects involved in its use. This apprehension is evidenced in Dr. Smith's exhortations to his colleagues to overcome their fears of anaesthesia. "Neither prejudices nor ignorance of its effects should longer prevent its employment by every operator [i.e. surgeon]" (1852:22). But his colleagues had little cause to be sanguine about the overall virtues of gas. On the one hand there were philosophical grounds for their fears, such as those advanced by Pierre Flourens, who held "The public is misled by the fact [378/379] that after an operation [employing chloroform] the patient is unable to remember what he had undergone," basing his argument upon physiological speculation (cf. Horkheimer and Adorno, 1972:229). On the other hand, there was empirical evidence to substantiate their apprehension. Dr. D. H. Agnew summed up a number of studies which suggested that the mortality rate of surgery did not decrease following the introduction of anaesthesia, and indeed may have increased. Agnew, apparently more sanguine than Flourens, tried to account for these facts by suggesting that industrialization had "materially changed the character of the injuries for which operations are required at present" (Agnew, 1881, Vol. 2:282). More severe injuries would presumably have higher mortality rates, apart from the issue of the competence of medical-surgical practice. Flourens dourly suggested that "with the increasing superficiality of the general training of our doctors, the unlimited use of chloroform may encourage surgeons to carry out increasingly complex and difficult operations" (Horkheimer and Adorno, 1972:230). Presumably this would have resulted in the increase in the mortality rate. Whatever the difficulties in assessing the causes of changes in the mortality rates for surgery, even the facts of the matter were not easy to come by. As late as October 1876, then Assistant Surgeon General Crane issued Circular Order No..2 requesting "precise data relative to the effects of chloroform and ether."/2/ Thus it is clear that ignorance and fear of the merits of anaesthesia lingered in the medical- surgical profession well through the middle of the Nineteenth Century, mediated by the various medical institutions. Quite apart from the issue of the "delay" in the practical application of anaesthesia in surgery, such application still did not readily become state of the art in medical- surgical practice. Hence the overall development of surgical anaesthesia may not be adequately explained in its own terms, i.e. apart from the broader terrain of the emergence of modern medicine. Section III: Development of Antiseptic Surgery Other key elements in the emergence of modern medicine included the Nineteenth Century development of asepsis and the antiseptic surgery. The American physician, Dr. Oliver Wendell Holmes (1843), summarized the state of knowledge of puerperal fever during the first half of the Nineteenth Century: it was "so far contagious as to be frequently carried from patient to patient by physicians and nurses." He recognized that obstetrical care must be distinguished from pathology, remarking "how kindly nature deals with the parturient female, when she is not immersed in the virulent atmosphere of an impure lying-in hospital or poisoned in her chamber by the unsuspected breath of contagion." In fact, it was precisely the non-pathological nature of childbirth which provided maternal mortality rates in the "natural setting" against which the increasingly institutionalized and iatrogenic maternal mortality rates could readily be compared and medical-surgical practices such as asepsis could readily be tested. Holmes admitted (1843) that he didn't know the process of contagion, but he nonetheless offers an insightful prescription against puerperal fever: the physician who has attended a case of puerperal fever "should use thorough [379/380] ablution, change every article of dress, and allow twenty-four hours to elapse before attending to any case of midwifery" because "it is his duty to take every precaution to diminish [the expectant mother's] risk of disease and death" from contagious disease. A few years later, the Hungarian obstetrician, Dr. Ignaz Simmelweis instituted a prophylactic programme of disinfection by chlorine solution at the lying-in-Hospital in Vienna. This programme was based on Simmelweis' own researches on the aetiology of puerperal fever, researches which were needless to say informed by Holmes' study. The success of this programme was disseminated by his colleagues Dr. Karl Haller, Dr. Ferdinand von Hebra, and Dr. Joseph Skoda, and his former students Dr. F.H.C. Routh and Dr. Friedrich Wieger. While Simmelweis realized that puerperal fever was a collection of common symptoms rather than a disease of common origin (aetiology), like Holmes, he did not understand the process of contagion. While some of the most progressive thinkers of the age, including Dr. Ludwig Kugelmann, recognized and supported Simmelweis' work, the full acceptance of his insights awaited further developments.

In the late 1850's Louis Pasteur published his initial findings on the theory of fermentation. As a corollary of these studies, he realized that germs (bacteria) were causal agents in disease and contagion (putrefaction) as well as in fermentation. This discovery was the key to the understanding of the process of contagion. By 1863, a French physician, Dr. C. J. Davaine, had made the practical application of Pasteur's insights to medicine. The practice of antiseptic surgery, whereby the germs are not simply segregated from the wound by aseptic practices but are eliminated from the wound area was actively promoted by the French physician Dr. Gilbert Declat (1865) and the famous Englishman Lord Lister (1867). By 1865, the cognitive elements of modern germ theory and antiseptic surgery were readily available to the medical-surgical profession. Yet a number of historians have noted the slowness with which these elements became state of the art in medical-surgical practice (cf. Bernal, 1971:649-51). Thus we have good reason to conclude that technological developments such as surgical anaesthesia and aseptic or antiseptic surgery are at most necessary conditions of social change. It might still be argued that these developments are necessary in their severalty, but are jointly sufficient for social change. Let us consider this possibility. Section IV: The Emergence of the Modern Mode of Medical Production As Dr. G. T. Wrench has reported of early Nineteenth Century surgery, "the operations which were most commonly undertaken were amputations." While amputations were considered to straightforward as surgical operations, nonetheless they were fatal enough. One of the initiators of the surgical use of anaesthesia, Sir James Simpson, estimated the mortality rate for amputations in Edinburgh, Glasgow, and London at the time to be as high as 40 percent, more than three times the mortality rate in the country countryside (Wrench, 1913:129-32). He attributed the difference to the septic conditions of metropolitan hospitals. This is a clue to the complex totality of modern medical-surgical practices, the mode of medical-production, as well as to the Nineteenth Century developments of anaesthetic and antiseptic surgery. [380/381] Concerning more serious surgical operations, the pioneering American surgeon, Dr. Ephriam McDowell, stated that "the first and eminent surgeons of England and Scotland had uniformly declared in their lectures that such was the danger of peritoneal inflammation that opening the abdomen..... was inevitable death" (Flexner, 1962:113). Dr. John Bell, one of McDowell's teachers and a most respected authority, had suggested in his famous Principles, written around the turn of the century, virtually throwing up one's hand in the face of septicemia (Bell, 1810:25- 29). For the great fear of the surgeon was of this virulent form of sepsis or "putrefaction" in the terms of the day. Until this threat could be lessened by a suitable prophylaxis, surgery as we know it was impossible. Rather than a complex totality, the unity or integrity of the mode of medical production was only implicit. More to the historical point, surgery was a last resort quite independent of the patient's pain or the physician's diagnosis of a case./3/ Hence the use of anaesthetics may well be understood to have awaited prophylactic procedures in surgery. Of course there is another side to this medal. Major surgery was virtually impossible in the absence of anaesthesia. On the one hand the patient could enter fatal shock (Trent, 1946:505 ff.). On the other hand, the patient simply couldn't be stilled long enough, even by a group of "strong orderlies." As Rene Fülöp-Miller has put it, "He who could get through the work most speedily was accounted the best surgeon" (1938:389). Notice the allusions to the handicraft mode of medical production. Thus surgery was impractical prior to the practical application of anaesthetics; the development of prophylactic procedures in surgery can be understood to have awaited the use of anaesthesia. In the neoclassical economist's terms, antiseptics and anaesthetics are thus technical complementary goods for the surgeon and the demand for one would be expected to vary directly with the demand for the other (Hicks, 1946:92). /4/ While the demand for these goods can perhaps be understood in value terms, the complementarity of goods is, of course, an objective characteristic of these goods. But the complementarity of antiseptics and anaesthetics described by the neoclassical economist does not in itself constitute an explanation of the emergence of the modern mode of medical production wherein these 'goods' are integrated. On the one hand, there are objective differences among patients and their diseases which require differing 'production functions' for medical- surgical services. Those several production functions are themselves factors which must explicitly and problematically be introduced into the neoclassical economist's analysis. There are two directions the social scientist can take towards an adequate explanation in light of such complications. One is to acknowledge the inadequacy of neoclassical economics and strive for a comprehensive 'science of society' after the fashion of Comtean and neo-Kantian sociology (cf. Welty, 1984:102). The other is to abandon neoclassical economics altogether and turn to Marxist political economy. Thereupon the explanations of the developments of anaesthetic and antiseptic practices in surgery need become an explanation of the development of the complex totality of modern medical-surgical practices, rather than discrete explanations of discrete developments. Once the modern mode of medical production had formed, it articulated well with the simultaneously emerging finance capitalist formation of [381/382] modern industrialized societies. That form was characterized by the complete domination of industrial enterprise by the financial institutions. The dominant tendency under the regime of competitive capitalism was the concentration and centralization of capital through competitive pressures. Those occupations and industries which were only formally capitalistic were able to delay or deflect this process of concentration and centralization. An example would be the 'family farm' (cf, Mann and Dickinson, 1978). Another would be the medical and surgical professions. With the advent of finance capitalism, however, the dominant tendencies of capitalism were augmented by the incorporation of the hitherto only formally capitalistic occupations and industries into capitalism itself. Agribusiness has progressively encroached upon the boundaries of 'family farming,' coming to control agricultural means of production such as fertilizers and machinery as well as distribution channels such as the food processing and packaging industries. This has resulted in what is called "contract farming" where the farmer finally contracts with agribusiness for the disposition of his agricultural product, effectively removing his farm from the competitive market, effectively fixing the rate of remuneration of his labor, and effectively introducing himself into the working class. Likewise the medical-health organization has progressively integrated the medical professions into the medical-health hierarchy by coming to control the occupations of anaesthesiology and other 'allied health professions.' This integration corresponds to the process of removing the health care professionals from ownership and control of the means of medical production. On the one hand, as Fichtenbaum has stressed (1982/83), a great number of 'allied health professions' are subordinated -- as wage-laborers -- to the physician, who thus functions as a capitalist. On the other hand, this integration removes the means of medical production from the ownership and control of the physicians and surgeons themselves. Instead they find a suitable position in the hierarchy. About 50 percent of physicians are salaried employees and the percentage is still growing today, up from 40 percent during the past dozen years, with profound consequences (Roemer and Friedman, 1971). This incorporation of the medical professions enhances the corporate form of the medical-health industry. But it does not eliminate the social antagonism of health care and capitalism; rather it shifts the locus of those antagonisms. The increasing division of labor enforced in the corporate form of modern medicine has increased the trade union tendencies within the medical profession, especially among nurses. Doctors' strikes are even becoming common. Meanwhile the increasing dehumanization of health care has increased popular discontent with medical and surgical services. The resurgence of alternative health care such as nurse midwifery in the obstetrical field is a striking but not unique instance. Thus the several surgical technologies were incorporated into the emerging mode of medical production. The medical-health industry has also become well articulated with the finance capitalist formation. As such, it has become a subordinate element in the political and social process of that social formation. In conclusion, there can be no 'utopian' resolution of the problem of health care in the United States because the resolution [382/383] of that problem has become an element of the larger political struggle to be waged on the broader terrain of the regime of capital. But neither can there be quiescence in the face of this larger political struggle. The contradictions of capitalism as they manifest themselves in the medical-health industry compel participation in the struggle, and it is only through resolute struggle that the problem of health care in the United States can be overcome. But these issues are clearly the topic for another occasion./5/ Notes 1.) The author participated in the 1975 global poll described in George Gallup (1977). Random samples of respondents from Western Europe and North America answered questions regarding "Perceived Satisfaction with Personal Health" (Item 26), responses correlated positively with indices of social stratification. 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