The Economics of Pathological Laboratories

ScienceStudies_TriciaCloseKoenig 1

A review of Betwixt and Between: Production and Commodification of Knowledge in a Medical School Pathological Anatomy Laboratory, Strasbourg (mid-19th century to 1939), by Tricia Close-Koenig.

If anything is en vogue in academia it is the “valorization of knowledge”. Academics are requested to seek ways to capitalize their work, and in the process to give it societal relevance. This is not always an easy thing to do in History and Philosophy of Science, contrary to the discipline of medicine where relevance seems obvious, almost indisputable. Yet, so far the significance of economics for modern medicine and the commodification of medical knowledge have received little attention.

Tricia Close-Koenig’s dissertation is based on a thorough comparison of laboratory logbooks and financial data. She offers a new perspective on the day-to-day business of the pathological laboratory in Strasbourg and she particularly explores the importance of monetary and economic considerations for the making of medical knowledge. Moreover, she argues that the pathological laboratory marks the birth of a proto-knowledge economics in which knowledge can be transformed into substantial financial incentive and return. Close-Koenig’s  thesis, in other words, explains how the management of clinical laboratories became instrumental in turning medical practice into a costly and profitable enterprise.

The thesis starts with an intriguing double description of a day in the Institut d’Anatomie Pathologique laboratory in 1925. The first narrative is the story as it is traditionally told – it is essentially about the work of Pierre Masson, the director of the institute. The activities of colleagues, students and technicians all centre on the lab routine of Masson. The second account is about the financial side of the day’s work. It is no longer focused on Masson, but rather discusses the activities of the assistants dealing with the book-keeping. And not surprisingly it turns out that the latter is at least as important as the ‘scientific’ account – after all, the money generated in the lab not only enhanced the salaries of Masson and his assistants, but also the purchase of the latest instruments, books and techniques.

The Pathological Anatomy Laboratory in Strasbourg offers such an interesting case study, because it changed from being a typical German research institution into a characteristic French hospital laboratory after World War I. It was originally built by the Germans as a scientific laboratory not only providing space for fundamental research, but also representing the administrative, scientific and technological strength of Germany. Under French rule the laboratory became an essential part of the hospital (and patient-centered) organization. And it was precisely this change which made the laboratory susceptible to the commodification and commercialization of laboratory knowledge.

Close-Koenig explores (1) how knowledge was produced in the pathological laboratory and (2) how this knowledge was commodified and commercialized in a communicable form. Chapter 1 is on the history of (anatomical) collections with particular reference to the role of catalogues in pathological anatomy. For the purpose of cataloguing specimens were transformed into numbers and names. However, Close-Koenig argues that they were more than just inventories – they were integral to knowledge production as, throughout the eighteenth and nineteenth centuries, pathologists extracted new information from them in order to generate new knowledge. In a way, anatomical preparations transformed into paper specimen which were at least as important as the things themselves.

In Chapter 2 Close-Koenig shifts from anatomical museums to histology and histopathology laboratories. She argues that seen from the patient’s point of view a pathological preparation could not usually help the person it was extracted from. This changed with the influx of preparations surgically taken from living patients. Pathologists could examine lesions at an earlier stage and interact with surgeons to understand and treat diseases. With the growing emphasis on the diagnosis and treatment of living patients, pathological preparations were increasingly replaced with histopathological slides. At the same time the pathologists’ expertise shifted the boundaries between fundamental research and hospital practice.

This is particularly evident in the case of cancer, which is discussed in Chapter 3. Histopathological observations were crucial in the identification and treatment of cancer – they defined cancer as a disease of cells and tissues, which had determinate effects on the choice of therapies. As a result the pathologists’ knowledge had economic value for surgical, radiotherapeutic and radium therapy structures and it became necessary for the pathologist to codify and commodify his knowledge. For the pathological anatomy institute, the opening of a regional cancer centre in Strasbourg brought commercial change as the demand and market for their services emerged.

The economics of the pathology lab is discussed in the last chapter. Close-Koenig turns to an analysis of how the services of the pathology lab were commercialized, implying the monetarization of a healthcare service with the establishment of prices, units and profits. The institute increasingly provided a private paying service to private patients in hospitals and out-patient clinics as well as to medical practitioners outside Strasbourg. Consequently establishing pricing structures and accountancy practices became necessities in the pathology lab, which further opened the market for commercial medical services.

Tricia Close-Koenig’s dissertation shows that the laboratory lab at the Institute d’Anatomie Pathologique was “betwixt and between”, forever oscillating between knowledge production and commercialization, between medical school and the hospital, between material and intellectual, between honorariums and prices. Close-Koenig’s work offers an exciting new perspective on the clinical laboratory. It is down to earth in that it discusses money – an aspect that we normally rather not associate with the making of medical knowledge. However, as this thesis shows, commodification and the valorization of knowledge were of crucial importance in laboratory practices. A focus on the commerce of medicine will therefore have important consequences for the historiography of medicine.

Rina Knoeff
Faculty of Arts / History
University of Groningen

Primary Sources

Archives de l’Institut d’Anatomie Pathologique de Strasbourg
Archives de la Clinique Dermatologique
Archives du Centre Paul Strauss
Archives Départementales du Bas-Rhin, Strasbourg
Archives de la Faculté de Médecine de Strasbourg
Archives des Hôpitaux Universitaires de Strasbourg
Archives de la Direction des Affaires Sanitaires et Sociales du Bas-Rhin
Division des archives de l’Université de Montréal
Archives Nationales, Paris
The Rockefeller Archive Center
The Archives of the Johns Hopkins Medical Institutes
The Alan Mason Chesney Medical Archives
The New York Academy of Medicine Archives and Manuscripts

Dissertation Information

Université de Strasbourg. 2011. 426 pp. Primary Advisors: Christian Bonah and Patrick Llerena.