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Case and Series: Medical Knowledge and Paper Technology, 1600–1900

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The patient history is almost as old as medicine itself and still central to its practice. 1 From the few dozen stories of the sick on Thassos collected in the Hippocratic Epi-demics to thousands of them in thick volumes in early modern libraries to hospital records weighing tons, medicine has archived patient histories in their changing forms. Remarkably unexamined is how these generated knowledge. We aim to open up that question. How were generalizations drawn from amassed individual histories? Since the late seventeenth century, we suggest, one answer to this problem has been seriality. 2 The construction of series became a basic operation of medical knowing. We show how that worked and outline that history. Collecting, formatting, selecting, reducing, comparing, sorting — the key tech­ niques are those of mastering on and by paper. They come into play when an index is made, or in the library when books are extracted from (Section 1). They also have their home in offices, where forms are prepared for controlling the recording pro­ cess in hospital wards (Sections 2 and 5), or where the pages of thick registers from ward or morgue are gone over with marking pens and new registers made from them (Sections 3 and 4). That is why our story begins not with Hippocrates's Epidemics or with the creation of the medical canon in late Antiquity, but around 1600 as print­ ing and humanist textual methods were transforming the landscape of knowledge and came to bear on medicine. That is also why our story neither begins with nor privileges the period around 1800 when modern, clinical medicine is thought to have been born. We leave the story where it stood around 1900, by which time quantifica­ tion and graphical methods seemed to have ended the reign of writing in medical observing and knowing, yet in fact, as we shall show, perpetuated the history that had structured that writing. Collected patient histories have been the stable centre of medical knowing. As the organization of such collections has changed, so too has medical knowing. And because that organization, we shall show, derived from a wider history of ordering the world on and through paper, so too have the practice and products of medical knowing followed that wider history. From this perspective, neither the Paris clinical school nor the physiological laboratory appears in its usual decisive role. The paper technology of knowledge production in medicine did not consist of instruments made for the job. This differentiates our work from recent work on paper tools in science. 3 Our history of science is more a function of modern history — of printing and learned
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CASE AND SERIES: MEDICAL KNOWLEDGE AND PAPER
TECHNOLOGY, 1600–1900
Volker Hess
Charité Berlin
J. Andrew Mendelsohn
Imperial College London
The patient history is almost as old as medicine itself and still central to its practice.
1
From the few dozen stories of the sick on Thassos collected in the Hippocratic Epi-
demics to thousands of them in thick volumes in early modern libraries to hospital
records weighing tons, medicine has archived patient histories in their changing
forms. Remarkably unexamined is how these generated knowledge. We aim to open
up that question. How were generalizations drawn from amassed individual histories?
Since the late seventeenth century, we suggest, one answer to this problem has been
seriality.
2
The construction of series became a basic operation of medical knowing.
We show how that worked and outline that history.
Collecting, formatting, selecting, reducing, comparing, sorting the key tech-
niques are those of mastering on and by paper. They come into play when an index
is made, or in the library when books are extracted from (Section 1). They also have
their home in offices, where forms are prepared for controlling the recording pro-
cess in hospital wards (Sections 2 and 5), or where the pages of thick registers from
ward or morgue are gone over with marking pens and new registers made from them
(Sections 3 and 4). That is why our story begins not with Hippocrates’s Epidemics
or with the creation of the medical canon in late Antiquity, but around 1600 as print-
ing and humanist textual methods were transforming the landscape of knowledge
and came to bear on medicine. That is also why our story neither begins with nor
privileges the period around 1800 when modern, clinical medicine is thought to have
been born. We leave the story where it stood around 1900, by which time quantifica-
tion and graphical methods seemed to have ended the reign of writing in medical
observing and knowing, yet in fact, as we shall show, perpetuated the history that
had structured that writing.
Collected patient histories have been the stable centre of medical knowing. As
the organization of such collections has changed, so too has medical knowing. And
because that organization, we shall show, derived from a wider history of ordering
the world on and through paper, so too have the practice and products of medical
knowing followed that wider history. From this perspective, neither the Paris clinical
school nor the physiological laboratory appears in its usual decisive role. The paper
technology of knowledge production in medicine did not consist of instruments made
for the job. This differentiates our work from recent work on paper tools in science.
3
Our history of science is more a function of modern history of printing and learned
0073-2753/10/4803-0287/$10.00 © 2010 Science History Publications Ltd
Hist. Sci., xlviii (2010)
288 · VOLKER HESS AND J. ANDREW MENDELSOHN
reading, of bookkeeping and state administration, of management and organization
of labour in complex institutions — than of specialized scientific communities.
1. COMMON-PLACES AND INDEXES
As early as the sixteenth century, medicine amassed empirical patient histories in the
genres of ‘historia’ and the ‘observatio’.
4
Units of circulation and exchange in the
medical republic of letters, observationes (the plural) were collected in large volumes.
5
Among the earliest such collections was that of Wilhelm Fabry von Hilden (latinized
as Guilelmus Fabricius Hildanus, 1560–1634), amounting to 600 patient histories
from his sixty years of medical practice and learned life. In 1606 his Observationum
centuria prima appeared; the second Centuria followed in 1611. By 1627 the fifth
had appeared, and the last hundred were published in a posthumous complete edi-
tion of all six Centuriae.
6
Such was the scale and life-defining ambition of this early
modern medical activity. The example of Fabry will also show how such collecting
worked, what it meant, and what happened to its products.
Fabry’s Centuriae are anything but an organized collection of patient histories.
Nor are they a journal of his practice, histories of his patients recorded day by day.
Instead they took the form of a “common-place book” a locorum communium col-
lectanea, that is, the sort of collection of excerpts a scholar would build up over time
from his readings.
7
If Fabry found something noteworthy in a patient in his practice
or in his correspondence with colleagues or his reading of ancient and modern medi-
cal works, then he would set aside that published passage or that entire exchange of
letters or those pages of his practice diary, sometimes with his reflections, sometimes
not. Each of these very heterogeneous sheets or sheafs of text he numbered as an
‘observatio’. When these reached a hundred, he sent the pile for publication in
exactly the chronological order in which it had piled up, that is, in no other order
than that of Fabry’s life, filed and stored.
Made public, how was this common-place book supposed to be used? For the
busy reader who did not wish to read through all 600 observationes in order to select
some for excerpting into his own common-place book, there was the index. Even
the individually published Centuriae included a rudimentary index: a list of the
observationes, alphabetical by title keyword, along with page number.
8
For Fabry’s
posthumous Opera omnia of 1646, not just the observatio titles, but the entire body
of text was alphabetically indexed into a nearly 20-page Index rerum et verborum:
from Abdomen and Abortus to Urina and Vulnus. Under G, for example, are entries
for Gammarum, Gangraena, Gargarismus, Genu, and so on. The 30-some entries
for Gangraena, in turn, are sorted alphabetically from “Gangraena ex abcessu”
to “Gangraena ex vulneratu”.
9
The index belongs to the history of the book, of editing, publishing, and read-
ing. Invented before printing, only in the Gutenberg galaxy did indexing become a
knowledge-organizing practice unto itself, methodically developed, reflected upon,
and transmitted. Contemporary instructions describe the method in detail: notable
passages of text were copied, each beginning on a new line; the page of copied
CASE AND SERIES · 289
passages was cut up, the clippings sorted and pasted or sewn into a new order. The
index thus made the fruits of the private scholarly practice of ordering one’s common-
places available to every reader. It enabled the synthesis of ancient and more recent
knowledge into a Bibliotheca universalis.
10
And since the book is a reference work
that can be used to look up things ‘out there’ in the world, the index was not only
for finding one’s way in the book or library; it also mediated the use of the book as a
tool for understanding and acting in the world. Indexing was truly, as early moderns
saw and we shall now see more closely, demonstrating and discovering something.
11
What the editors of Fabry’s Observationes did in indexing them, the Genevan
physician Théophile Bonet did to the observations themselves. Bonet’s Sepulchretum
sive Anatomia practica of 1679 was the largest collection of observationes up to
its time; nearly 3,000 patient histories, each with autopsy result, supplemented by
Bonet’s learned annotations filled with referenced quotations from the whole canon
of Western medicine and sometimes extending over several of the 1,716 pages. To
make this collection, Bonet extracted worthy patient histories from Fabry and over
400 other authors going back to Hippocrates, cut them into pieces, and sorted the
excerpts into anatomical order from head to toe as was usual in the medical genre of
practica, approximately as would be done to make an index but cutting and sorting
entire excerpts rather than keywords. This practice was peculiar neither to Bonet
nor to medicine. It was standard scholarly practice for ordering loci communes, as
the botanist and bibliographer Conrad Gessner explained, “according to particular
headings and classes, whether in alphabetical order or according to genera and
the classes of philosophy or according to yet some other way”.
12
The aim was not
natural or philosophical order but access to the growing library of knowledge.
Thus disease collections like Bonet’s combined the goal of historia (comprehensive-
ness) with that of bibliotheca universalis: making navigable all written knowledge
while preserving, in the compact form of a single book, the empirical particulars out
of which that knowledge was made and, at the same time, establishing a structured
repository into which new particulars could be sorted.
What does this mean for our history of case and series? Commonplaces, not cases,
were collected and organized. Bonet was not determining for each patient history the
one category to which it belonged. Many patients appeared as more than one observa-
tio. And a single observatio could consist of as many as 30 patients, snippets of their
histories. So each observatio was neither a case nor a member of a series. It was the
place — hence locus, toposfor remembering one’s readings of relevant histories.
Thus did scholarly paper technology produce a topical, not a serial order of disease.
Alphabetizing, too, as Gessner explained, could make accessible the library of
medical knowledge. In 1713 Fabry’s 600 observationes were published anew. The
editor of this new edition, the Strasbourg anatomist Johann Sigismund Henninger,
cut out everything irrelevant (“prolixioribus formulis epistolicis” etc.) and promised
the buyer a sure order (certa ordo) — alphabetical order.
13
Easier said than done: how did Henninger decide what elements and aspects to
alphabetize? No Bonet spending his life in the library, Dr Henninger helped himself
290 · VOLKER HESS AND J. ANDREW MENDELSOHN
to the past labours of the makers of books: he used the alphabetical Index rerum et
verborum made by the publisher of the 1646 Opera omnia edition of Fabry. The
index, a finding aid constructed by extracting keywords, was in Henninger’s hands a
template for extracting texts. This rearrangement can be imagined as an act of physical
sorting: Henninger took the pile of Fabry’s first centuria of observationes, trimmed
them to the essentials, and dealt them like cards into piles corresponding to entries
in the 1646 alphabetical index; then he did the same with the second centuria, and
so on. Now the observationes themselves ran from abdomen and abortus to uterus
and uvula. Index became book.
But with one consequential difference: an observatio could be entered into an
index under as many keywords as needed, but it could go into only one place in the
new, alphabetized book. Could not an observatio appear, say, in G under Gangrene
and, as in Bonet’s technique, a partially duplicative extract of it in A under Abscess?
Not in practice: such duplication and scattering was naturally limited under topical
order, but under alphabetical order it could go on and on: every medical term could
be alphabetized, each patient history multiplied into dozens of extracts in as many
locations in what would then be a very cumbersome book. Moreover, norms of the
book were changing between Bonets seventeenth century and Henningers eighteenth.
Now only “pedants” made long and elaborate indices instead of writing books that
did not need them. Academic barbarism, the Enlightened charged: enough of reading
as “looking things up here and there”. “Everything in a proper order” was the new
maxim,
14
and Henninger’s certa ordo made this a reality. Where in Fabry’s Opera
omnia related observationes could only be found via the index and each could be
indexed multiple times, here everything had its proper place.
This had unintended consequences. Alphabetizing generated clusters. For each
observatio groupable under gangrene”, there was only one place. So all gangrene
histories were now clustered onto pages 501–35.
15
Printing them together could
sediment a picture of a disease condition, making the observationes less like com-
monplaces and more like “cases of” that condition. Since paging from 501 to 535
is a linear act, the cluster reads as a series. But the membership and sequence of
the series is not meaningful. Under gangrene” (and any other heading), the patient
histories remain in the original order of the centuriae a chronological series by
date of acquisition, bits of Fabry’s vita, hidden in the alphabetical series. Alphabeti-
cal or chronological, such sequences were arbitrary with respect to natural order and
medical knowledge.
We would make two further points here.
Alphabetizing, and therefore its case-clustering effect, was an empirical process.
The clusters and their headings were to some extent results and not only givens.
This was empiricism carried out not on nature but on the book. And it took the
form of work on categories. In Fabry’s Opera omnia, for instance, ‘gangraena’ and
sphacelus’ were separate index entries. This made sense because Fabry’s treatise
on the differences between the two conditions “warm” and “cold” Brand in
eighteenth-century German was bound among the Opera. But when Henninger
CASE AND SERIES · 291
finished sorting the observationes, he found but one observatio in the “Sphacelum”
pile.
16
A single observatio did not deserve a separate place in the new, alphabetical
order. Henninger’s book-technical solution to this book problem reversed Fabry’s
intellectual effort to differentiate the two conditions. The sphacelus observatio was
put under G in the gangrene cluster. Yet under S in the index, sphacelus did get an
entry: “vid[e] gangraena.
17
The second point is that this empirical category work was not intended. It happened
through alphabetizing. And, more specifically, this disease category work, as in the
example of gangrene and sphacelo, was a side-effect of generic category work. Hen-
ninger’s alphabetical headings were of all kinds: anatomical-topographical such as
abdomen or uterus; disease phenomena such as catarrh, iliaca passio, and gangrene;
or causes such as “morsi” (bite injuries). So whatever happened to disease headings
happened inadvertently. Take “M” in the Opera omnia index. Henninger followed it
from entries on uses and effects of mercurius through observations of mola and diverse
morbi to illnesses caused by human and animal bites morsus yet found, along
the way, that he could consolidate categories by moving observationes indexed as
micturition difficulties to the heading urina. This was the same paper-technological
move as putting sphacelus with gangrene.
To conclude: the chronology of the medical practice, reading and correspondence
of a physician like Wilhelm Fabry was once a perfectly adequate order in which to
publish 600 observationes in six books. Then, operating iteratively across disparate
users and in stages over the following century, bookish paper technology cut up an
observant life into an alphabetical collection of observations. Some of these were
meanwhile put into topical order in larger collections like Bonet’s: the early modern
period had various ways of dealing with empirical mass. The use of paper technol-
ogy in indexing and alphabetizing had inadvertent effects, notably clustering and
category work. Neither of these made epistemically meaningful series; but both were
prerequisites for such series making.
2. STORIES FROM TABLES
Indexing is a technology of the book. It orders post hoc. A collection in chronological
order of acquisition (Fabry) becomes topical (Bonet) or alphabetical (Henninger’s
Fabry). Using different paper technology, order could be pre-scribed instead. Ques-
tionnaires, hand-drawn columns or tables, or printed schemata: all such formatting,
prescriptive in both the normative and literal sense, operates by fill-in-the-blank.
Designed to ease the collection, organization, and storing of knowledge,
18
prescrip-
tive formatting also had unplanned effects, among them the production of series.
This happened in a particular period in the history of paper technology and its use,
during the late eighteenth and early nineteenth centuries.
The technology of paper pre-scribing comes from early modern state administra-
tion and accounting. Its most elementary practice is the keeping of a list or ‘register’
usually page by page in a book, hence bookkeeping. In Prussia, for example,
population registers (Populationslisten) of baptisms, marriages, and deaths began to
292 · VOLKER HESS AND J. ANDREW MENDELSOHN
be kept in 1688.
19
Multiple kinds of data could be registered at once — or account of
income and expenses kept — by dividing the pages into columns. By 1722 Prussian
administrators were keeping “historical tables [Historische Tabellen]” with rubrics
for 24 different kinds of information about the country. These were then summarized,
through a process of several steps, into a “general table [Generaltabelle]” meant to
make visible “the state of the entire monarchy on a sheet of paper”.
20
These same tools and practices and this same history, we shall now show, were
recapitulated in that other emerging space of administration: the hospital.
Just as the state had begun registering births and deaths, the hospital registered
patients entering and leaving with columns for name, age, date of admission, date
of discharge, and usually other data such as occupation. Thus could patient numbers,
supplies, expenditures, and revenues be controlled. In such a register, each patient
got but one entry for his or her entire stay in the hospital. Daily registration of data
about patients, such as meals provided and treatments administered, emerged in the
eighteenth century with the incorporation of medical personnel into the hospital’s
administrative routine. Such practice did not necessarily include recording medical
observations.
21
Yet daily formatted medical observation could grow on the model of
the register — or even on existing registers, as already used in hospitals, simply by
adding more columns. Proposals to do one or the other of these circulated in books
and journals in the mid-eighteenth century.
22
Only in the hospital did these models
meet doctors who, increasingly accustomed to pre-scribed administrative writing,
were ready to use them. By 1795, for example, we find trainee physicians in the
clinic of the Julius Hospital in Würzburg, under Johann Georg Christoph Siebold’s
directorship, required to enter daily observations of their patients in a prescribed,
three-column table in their journals and each day to present this to the clinical instruc-
tor (see Figure 1).
23
Würzburg is one example among many (Figure 2).
24
Administra-
tion reshaped medical observation and recording not only through such schemata
but also through the all-but-pedantic clerkish norms of their use. That special “order
and punctuality, as it forms the soul of the hospital institution”, governed the act of
writing. Clinicians like Siebold elevated hospital discipline “to precept and norm”
of observation.
25
Physical formatting on paper went hand in hand with psychological
formatting on duty.
The effect of prescriptive formatting reached far beyond the ward journal to what
was published on its basis. Consider the cases published by Anton de Haen, leader
of the ‘Vienna school’ (circa 1745–1800) which carried on the tradition of the small
clinic, or Theatrum nosologicum, begun by Boerhaave in Leyden. What must have
been a tabular formatted ward journal shines through the published page. The column
for Dies morbi has become the margin. Treatments, too, appear there for instance,
“V.S.” for Venae Sectio or bloodletting. The column for Dies mensis is reproduced
by printing the date of each day’s observations in italics. Observation disciplined
by hospital regime, with bedside measurements from 10 a.m. to 10 p.m., appears in
print as well: “ad 10. ictus 120. ad 1. 116. ad 3. 124. ad 5. 120. ad 7. 114. ad 10 ictus
120. & calor 103 gr.” The printed page equally reflects the limits of the formatting
CASE AND SERIES · 293
on the ward journal page, namely, the lack of more columns and rows: what must in
the ward journal have been a wide column for writing down all observed symptoms
(as in Siebold’s schema too) remains, in print, page-wide blocks of text, each begin-
ning with the italicized date of observation. Temperature and other measurements are
jumbled into the daily text: presumably the ward journal lacked columns for these.
26
How far this was from the patient history as observatio, as prose narrative short
story with beginning, middle, and end — written up at the end of the illness. What
did this mean for medical knowledge? Prescriptive formatting on the administrative
model standardized patient histories and (partly) divided them into elements; this
made them comparable and combinable. By the nineteenth century, there were two,
Fig. 1. Clinical form for taking a patient history, as used in clinical training in the late eighteenth century.
From Johann Georg Christoph Siebold, Vorläufige Nachricht von der gegenwärtigen Einrichtung
des Klinikums an dem Julius-Hospital zu Würzburg unter Aufsicht des Professors Siebold des
jüngeren: nebst einigen allgemeinen Bemerkungen über Spitäler und klinische Anstalten in
akademischer Hinsicht (Würzburg, 1795). By permission of the Göttinger Universitäts- und
Staatsbibliothek.
294 · VOLKER HESS AND J. ANDREW MENDELSOHN
interrelated chief forms of such combination: the series and, as we shall glimpse
more in the next section, the general observation or general description. These were
actors’ terms as well as ours. Neither was possible without the rise of formatting.
Recorded with “precision and reliability” in uniform tabular format, illnesses on
paper invited their compilation into a synoptic tabular “Index of All Diseases from
August 1790 to 1791”. So the director of the Berlin clinic, Johann Friedrich Fritze,
titled the table into which he sorted the formatted illnesses recorded by his students
Fig. 2. Hospital form for taking a patient history. The so-called Journalblatt is one of the earliest kinds
of hospital patient record we know. Shown here is the front of the folded sheet that doubles as a
patient file folder. Charité Berlin, 1824. From Geheimes Staatsarchiv Preußischer Kulturbesitz
(GStAPK), 1. HA 76 VIII A Nr. 2182 Acta betr. die angeblichen Heilkräfte des Dienstknechts
Grabe, vol. ii, by permission of the GStAPK.
CASE AND SERIES · 295
from fever to venereal disease and which he published as part of a contribution
to medical knowledge.
27
Even this process of synthesis was scripted by administrative
paper practice for administrative purposes: Fritze, like other hospital chief physi-
cians, was required to submit weekly, monthly, and quarterly tabular overviews to
the Prussian medical department.
28
And, finally, what thus happened in the hospital
via the paper technology of administration of the state reproduced what happened
in the state itself via the same kind of paper technology and recapitulated its history:
state population register parallels hospital patients journal; 24-rubric state “histori-
cal table” parallels monthly tabular hospital report; “general table” of the monarchy
parallels tabular “Index of All Diseases” .
Medical knowledge could hardly stop here, with a tabular index of all diseases
in given periods. Yet Fritze found it difficult to proceed further. As easy as it was
to read off data from the formatted journals, knowing how to evaluate the columns
of abbreviations, terms, and half-sentences and thence produce “reflections on the
patient history contained therein” was not so simple. Never did the “inadequacy of
our journals” stand out to Fritze so clearly as in that effort of synthesis at his desk.
29
Narrative gave Fritze a way. Beyond the tabular index, his Annalen des klinischen
Instituts present neither periodic reports nor collected patient histories. Instead they
tell. They put particular histories into a general one. The model for such a general
history was the genre of annual disease history, or ‘constitution’, exemplified by the
Observationes medicae of the seventeenth-century neo-Hippocratic English physician
Thomas Sydenham. Yet Sydenham, despite the title of his book, did not publish or
even summarize the patient histories that made up his annual histories.
30
Fritze did.
He dissolved the sequence of illnesses in the Berlin clinic’s patient journals, which
was merely chronological by date of admission, and regrouped and rewrote them
as the morbid history of the year. First he summarized “the fourteen [patients] who
suffered from hectic fever”. Then he separated this group into those “who were admit-
ted in November and December [1790]” and those with the gastric fever of the new
year, which took “a somewhat different form”, namely, “markedly more mucous”.
31
Like Bonet or Henninger a century or so before, Fritze thus grouped patients under
headings, such as hectic fever and gastric fever. But unlike those earlier organizers of
observationes, Fritze related the cases in one box with those in the next one, as in the
example of the spring fevers displaying markedly more mucous than the winter ones.
Bonet makes visible no such relations: the observationes in any box, any category,
are as unrelated to those in the other boxes as one topic differs from the others. The
order is topical in the literal sense of topos; it is by place in the body. Moreover,
within each category in collections like Bonet’s and Henninger’s, the sequence of
observationes is arbitrary. Not so in Fritze’s collected cases: each case follows logi-
cally from the previous one. Greater detail in a patient history was presented not
for completeness but for its relationship to the next. If one patient history provided
evidence of the healing influence of unrestricted breathing, then it was followed by
a further history “of this kind”.
32
Had an editor dropped a couple of Fritze’s patient
histories or moved them elsewhere in his report which was the very essence of
296 · VOLKER HESS AND J. ANDREW MENDELSOHN
what Bonet and Henninger did to collections of observationesthen its meaning
would have been lost. The rationale of Fritze’s sequence makes it belong to a general
observation instead of remaining a collection of observations.
This, then, is a series and what produced it. No formatting and tabular overview,
no narrative serialization of the collected histories. How exactly Fritze got from table
to story remains mysterious. This is not simply because the intermediary manuscripts
are lost. There was a Gordian knot, evident in Fritzes realization of the inadequacy of
the formatted journals whose keeping he and his institution instilled in the students.
On the one hand, tabular formatting enabled the compilation of observations into an
annual synopsis. On the other hand, the ultimately administrative format’s own rigid
divisions blocked the writing of a synoptic history. The missing link from table to
story involved remembering as well as reading. Without memoria, no historia: had
the clinic director’s “memory not come to [his] aid at various points”, there would
have been no disease history of the year.
33
This happened off the page. But the table
could occasion and structure it: where the schema ends, memory springs.
3. SERIES WITHOUT NARRATIVE
To go from particular narratives to a general narrative — from histories of patients
to the general fever history of the year required passing through the non-narrative
form of the table. This prompts two questions. Could generalization of cases occur
without narrative at all, without that fundamental structure of natural history? What
logic of sequence could series have other than that of a history? And left over from the
examples of Siebold and Fritze: how exactly did formatting make possible seriality?
A change of scene will enable answers to these questions. Paris in the first half of
the nineteenth century is generally acknowledged to have been the capital of Western
medicine, not least because it was capital of the cadaver. The signature of the Paris
clinical school was systematic comparison of bedside and postmortem observations,
symptoms and lesions. But how did such comparison over many cases work? How did
it produce general knowledge? Our answer is that revolutionary Paris medicine was,
in this crucial respect, business as usual medicine in the reign of paper technology.
Here, to pick up where we left off with Siebold and Fritze, we shall find cases and
series neither of which were narrative. In the absence of narrative structure, in the
newer science of pathological anatomy as much as in the older one of Hippocratic
constitutions (e.g., Fritze), the same overall history unfolds, of increasingly adminis-
trative paper technology at work: keeping registers, tabular formatting, and a practice
we saw so far only in its scholarly mode, extracting.
Among the most influential teachers of the “Paris school” of clinical medicine was
Pierre Charles Alexandre Louis. His best-known work, Researches on typhoid fever,
appeared in 1829.
34
The book is divided into four parts. The entire first part consists
in a series. Eighteen cases, each with clinical history and autopsy report, are appor-
tioned into three chapters. No titles announce purpose and structure. The cases simply
appear one after another, numbered Observation I through to Observation XVIII.
CASE AND SERIES · 297
On closer inspection, Louis’s Observations I–XVIII turn out not to be collected
observationes in the early modern mould. Instead, they form an argument. Observa-
tions I and II are presented as essentially identical and as featuring without compli-
cations the lesions that Louis finds in most cases and, above all, the lesion that he
finds in all cases and that, he will argue, therefore defines and causes the disease.
This definitive lesion is pathological alteration (mainly ulceration) of the elliptical
plaques, or “Peyer’s patches”, that protrude slightly on the inner wall of the small
intestine. (In fatal cases, such alteration was seen to reach the stage of intestinal
perforation.) The next case in the series makes clear the logic of this argument and
therefore of the sequence: Observation III lacks the softening of heart and liver tissue
found in Observations I and II. Hence this softening must be considered “une lesion
accidentelle” rather than essential to the disease.
35
The logic is thus one of exclu-
sion: Observation III excludes certain pathological alterations from being the “seat”
of the disease. Chapter 1 of the series concludes with a doubt: physicians disagree
about the role of the plaque alterations because patients usually succumb after a
more or less prolonged period and the lesions could therefore be suites (sequelae) of
the disease rather than its “seat”.
36
The next sub-series of cases dispells this doubt.
Whereas Observations I–VII were all of the usual 16–30 days in duration, Obser-
vations VIII–XIII are cases of 8–12 days. These “acute” cases allow Louis to look
for the lesions as early as possible in the illness. Here, too, he finds the intestinal
plaque alteration. It must, he concludes, be seat and cause and not merely effect of
the disease. Finally, Observations XIV–XVIII, comprising the third and last chapter
of the series and all of longer duration (more than 30 days) show the lesion in its
“diverse modifications” and thus secure the disease category around such variety and
distinct from acute fevers with which typhoid shares most lesions and symptoms.
37
In short, where Fritze’s cases exemplify the series as narrative, Louis’s exemplify
the series as argument.
How did Louis construct series and argument? The answer would usually be: sta-
tistics of lesion occurrence, or what he and others called his “numerical method”.
38
Yet how did he know what to count and how did he have countable things, that is,
countable elements of cases? There are two answers to these questions. Each involves
paper technology and the histories to which it belonged.
Prefacing each observatio is an abstract of its symptoms and lesions. No ordinary
abstracts, their form and content suggest they were written before the case histories
they preface and in the process of knowledge-making. The technique in evidence is
extracting. We witnessed bookish uses of extracting in early-modern learned medicine.
By the later eighteenth century, extracting had expanded beyond medical scholarship
to become central to routine medical observation in France. After the Revolution, it
was institutionalized in Paris medical training.
39
To extract was to condense patient
histories and make them comparable with one another. Hence it required selection.
There were degrees of selectivity. Pierre Louis’s published case-prefatory extracts
are highly selective in quantity: a few lines for an entire case. And they are highly
selective in quality: their elements are selected and arranged according to features
298 · VOLKER HESS AND J. ANDREW MENDELSOHN
more or less shared among all of the cases. Notably, the autopsy extracts all begin with
the lesions found in all cases — ulcerated intestinal plaques and altered mesenteric
glands and move toward lesions found in many cases, such as softening of the
viscera, to those found in only a few. In short, these extracts are not abstracts or
summaries of each patient history as such, but rather extracts from each history as
element in a series.
The circular epistemic problem here is that Louis could only know what to extract
once he began to see patterns and yet he could only see patterns via extracting. So
he must have begun by extracting everything. And he must have had an instrument
of arrangement, comparison, and selection. Indeed he did.
Eight years after publishing Recherches, Louis published an excerpt from the key
instrument of its production: a “Tableau anatomique” (Figure 3).
40
Knives could
dissect the body physically on a table; the paper table could dissect it epistemically.
The tableau anatomique is a table of autopsy results. Each patient gets one row
in the table. The rows are divided into 15 columns. The first four columns are for
case number, sex, age, and duration of illness till death; the remaining eleven, for
observations. Whereas observations would initially have been recorded under only
three headings corresponding to the three body cavities opened during dissection
abdomen, chest, head
41
the columns in the tableau divide each patient’s body into
ten organs, plus a column for external appearance.
The combination of rows and columns divided and distributed a prose report into
Fig. 3. Pierre Charles Alexandre Louis, “De l’examen des malades et de la recherche des faits généraux”,
Mémoires de la Société Médicale d’Observation, i (1837), 1–63. By permission of the Académie
Nationale de Médecine, Bibliothèque, Paris.
CASE AND SERIES · 299
comparable units. In principle a patient history could be divided up — analysed —
in myriad ways. The practice of bibliotheca universalis, which we saw in Bonet,
divided each patient history according to its unique combination of features rather
than preset categories (as in the columns) insofar as these features were shared —
that is, could be put in boxes entitled (tituli) a or b or c with similar features from
other otherwise unrelated histories. In contrast, the tableau anatomiques columns
and their headings divided each sick individual’s body each row of the table in
exactly the same way.
The table not only took the same multiple-cookie-cutter extracts out of each
patients body record, column by column, but also stacked these, row by row. Stacked
extracts allowed counting of a certain kind. Running the eye down any given organ
column and keeping the duration column in view, one would see in an almost auto-
matically tallying mode what proportion of cases, in each duration range, presented
a given range of descriptive terms. And meanwhile, through this same activity, that
range of descriptive terms reified into a lesion type. How different this tallying of
present or absent elements was from the clustering of similar yet variant features in
the seventeenth- and eighteenth-century observationes literature. The table’s struc-
ture made the difference. The “numerical method” was, in short, tabular tallying: in
practice no more a product of statistics than of bureaucracy.
Autopsy was shot through with administration: the hospital morgue was charged
with a publicly and privately significant task, the management of dead bodies and
information about them. This was done using that basic administrative paper and ink
instrument, the register.
42
The tableau anatomique of Pierre Louis was a register in
form. It was also a register in use: unlike a table published in a book, it was viewed
iteratively and data were extracted both into and out of it. Extracting selectively from
the table by column yielded the anatomical “general description” of the disease
Part 2 of Louis’s book organ by organ. Extracting selectively from the table by
row yielded the series as argument — Part 1 of the book, Observations I–XVIII.
But not directly. What Louis published as abstracts of the case histories read as
though they are those very extracts, by row, from the tableau.
43
Though not tabular,
they display the effects of the manuscript tabular form — exactly as the cases pub-
lished in de Haen’s Ratio medendi of 1779 display the effects of a tabular ward journal
in the Vienna clinic. Reading each is like reading selectively across a row in the table:
duration of illness in days, instead of occupying a column, is set off in italics (like
the calendar date in de Haen) followed by anatomical changes in groupings that are
not systemic but match the column divisions in the tableau.
These extracts from the tableau formed, at last, a homogeneous series of cases,
for which the histories could be written last and, in knowledge-shaping power,
least. These histories were now cases whose variety was serial uniform along a
single axis rather than topical in all directions, by any occurring feature, as in
the observationes grouped under disease headings in the early modern collections.
If this account of the making of what is arguably the exemplary work of Paris medi-
cine after Laennec seems overly reductive, consider that Louis’s Recherches contains
300 · VOLKER HESS AND J. ANDREW MENDELSOHN
not a single reference to any previous work on its subject, nor to any physiological
or pathological concepts or theories. It uses only descriptive anatomical terms and
argues solely on the basis of the effects and outputs of a paper machine that Louis
developed but did not invent and whose operation and wider history we reconstruct
here. How could it be otherwise? Only recursive use of the table could determine
what to extract into the table, what to leave out, what later to bring in or get rid of,
and the categories into which rows could be marked or restacked into meaningful
series. In short, if Louis’s practice seems somehow bureaucratic, it was. Clinical and
pathological research at its most rigorous, quantitative, ‘scientific’ belongs to the
history of administration and its paper technology. That, as much as anything, was
what the hospital did to medical knowledge.
4. RECOMBINABLE SERIES
How representative is Louis, who, after all, was famous in his own time for train-
ing students in meticulous medical recording and specifically in keeping autopsy
registers? To show how widespread such knowledge-making paper practice was, we
jump from the Paris Charité to the Berlin Charité, and from pathology to psychiatry.
This section will also show the appropriation in an administrative context of a paper
practice we met in its earlier bookish mode: indexing. Here, moreover, it will be
seen in action.
The hospital began administrative life as a uniform closed space whose door was
kept by a bookkeeper bent over a large ledger. Internal differentiation followed via
departments, new forms of cost reimbursement and accounting, and the integration
of clinical teaching. Differentiation ended the reign of the single ledger.
44
At the end
of the eighteenth century, the Berlin Charité Hospital administration used six pre-
printed forms. By the mid-nineteenth century, more than 30 different administrative
schemata were being printed from the “Work Hours Journal” to the “File Circula-
tion Journal” to the “Birth Register for the Church”.
45
The point, however, is that this
bureaucratic and paper differentiation and specialization linked rather than separated
the increasingly differentiated fields of medicine in the hospital. The same forms were
used in the department of internal medicine, the department of surgery, the depart-
ment of gynaecology. And the same generic pre-printed formatting served recording
for knowledge in very different spaces of knowledge. In the Charité morgue, Rudolf
Virchow recorded autopsies in the same sort of thick, large-folio volume pages
pre-printed with columns as was used in the outpatient Neurological Polyclinic.
46
On paper, the distance even from outpatients to the pathologists was short. Shared
tabular journal formatting gave different disciplines a comparable data structure and
generated in paper-and-ink structures the basis for a unified body (of knowledge).
How this worked can be seen in those Polyclinic journal volumes. The polyclinic
was among the new institutions of the nineteenth-century hospital that, in effect,
brought the city into the hospital. The Polyclinic permitted more observations
through high patient turnover rate and funnelling of interesting cases past competi-
tion with other clinical departments into its own wards.
47
The recording system
CASE AND SERIES · 301
reflected this mediating function between in-patient and out-patient care. On the
one hand, the pre-formatted journal that was kept in the Polyclinic, as it was in the
morgue and Pathological Institute, conformed to the format of registers as it had long
been standard in hospitals. On the other hand, in the Polyclinic, this type of journal
was nonetheless kept as a practitioner would keep his casebook. The columns for
numerus currens, name, age, occupation, address, and diagnosis are followed by a
wide column in which the pre-admission history, clinical observations, and clinical
course are entered in free form over several lines and occasionally even pages.
48
This
unrestrained, practitioner-casebook-like writing broke the strict limits a register’s
rows would normally impose yet retained the register-like feature of stacking cases
in a columned format that invited viewing them in series.
The invitation was taken up. Paging through the dozens of volumes of these
Polyclinic journals, one notices that others long ago have also paged through them
and have left in the numerus currens column all sorts of pen and pencil markings of
this specific reading activity. In the volumes for 1888–92 for instance, many cases
are marked with a diagonal blue double dash. Others are marked with a horizontal
blue or black dash, or vertical blue, diagonal red, or four dashes in black, and so on.
Only following such series of markings over several months begins to make clear
their logic. Page by page, the diagonal blue double dash marking builds up a cluster
in the diagnosis column: paralytic trauma of the Nervus facialis; traumatic neurosis;
alveolar fracture and traumatic neurosis; Dolores vagi; railway spine; sequelae of
an earlier fracture; traumatic neurasthenia; traumatic reflex psychosis; paralysis of
the left side of the body; traumatic neurosis; and so on. All have to do with trauma.
Such marking was not invented on the spot, for the job. It belongs to a generic paper
practice we have already seen from an earlier, bookish era: extracting. Even the spe-
cific practice of extracting by using pen and pencil strokes in the numerus currens
column to mark journal entries in selective series was, at least at the Berlin Charité,
generic: autopsy registers in the very different space of the Charité morgue, that is,
in Virchow’s institute, bear the same sort of indexical markings.
49
Further deciphering of the Polyclinic journal requires some context. In 1889 Her-
mann Oppenheim, assistant professor at the Berlin psychiatric clinic, published a
monograph on “traumatic neurosis”. His goal: to subsume the older disease identity
“railway spinewithin a more general one and to separate it clinically from psychiatric
conditions associated with concussion.
50
This was no foregone conclusion: it met
criticism, and only after the First World War was there consensus on the independ-
ent identity of traumatic neurosis, its aetiology, and treatment. Medicine today looks
back on this as the forerunner of ‘post-traumatic stress disorder’.
51
The content of the debate and Oppenheim’s work is known. Not so the paper
work behind it. The marking procedure was indexical, but not simple. It indexed not
the case labels in the diagnosis column (such as the first 10, listed above) but the
accompanying clinical description. The same circular extracting process that in Pierre
Louis’s typhoid fever was made possible by the tableau anatomique was here made
possible and structured by the pre-printed tabular Polyclinic journal. Notable entries
302 · VOLKER HESS AND J. ANDREW MENDELSOHN
in the diagnosis column led efficiently — amidst the hundreds of folio pages — to
their accompanying, potentially relevant much longer entries of patient history and
clinical observations, each of which was then read in order to determine which case
should be pulled — marked — out of the journal’s purely chronological series into
an emerging diagnostic series and disease category. Entirely different diagnoses,
such as reflex psychosis and traumatic neurasthenia, were thus grouped together. And
vice versa, these original diagnoses were put to the test: not every reflex psychosis,
traumatic neurasthenia, or other post-traumatic complaint was marked into the group.
Occasionally the original diagnosis was amended.
Just as Pierre Louis extracted all lesions into his register-like tableau anatomique
in order then, in a second round, to extract those most frequent lesions that came to
constitute the disease, so too the Berlin Psychiatric Polyclinic’s register-like jour-
nal structured a second round of this virtuously circular process. The blue-marked
selection of about 100 cases was subjected to a critical review. Now the blue dashes
served as an index, leading the testing eye from one selected entry to the next. More
than one-fifth of the marked cases failed to withstand this second reading and were
excluded, their marks crossed out with black ink (Figure 4).
Together the old administrative technology of the tabular register and the old book
technology of indexing could forge something new: a disease-defining series. A series
of 33 case “Observations” concluded Oppenheim’s monograph defining traumatic
Fig. 4. Patient records in the form of a ledger. Bandakte der Poliklinik der Psychiatrischen und Nervenklinik
der Charité, 1888–1890. Institut für Geschichte der Medizin, Charité Berlin.
CASE AND SERIES · 303
neurosis just as Louis began his monograph defining typhoid fever with a series of 18
case “Observations”. Oppenheims’s, too, were written last, not first; they are extracts
— partly verbatim, partly purified and standardized — from the journal record.
52
Yet there was also a difference between Oppenheim and Louis. Unlike the cases in
Louis (and Fritze), those in Oppenheim’s series are pure and stand-alone histories: no
interpretative comment, no references from one to the other, each case an independent
unit to the point that Oppenheim and his students recombined them verbatim into
series in other publications. Still, though no explicit argument embeds and links them
as in Louis’s series, their sequence is not arbitrary. The clue is that each begins with
the cause of the neurosis, the trauma. Trauma here meant bodily shock or injury, but
not to the brain. Oppenheim’s series distinguished traumatic neurosis from conditions
of the mind dependent on injury to the brain (e.g., aphasia) and pictured it as a fun-
damental, almost specifically psychiatric expression of a modern world of accidents,
of routine bodily injury. This was the world of high-speed mass transport, ubiquitous
construction, and industrial machinery: from the dangers of railway travel (the first
12 cases in the series) to consequences of a fall (from a machine, from a horse, from
a railway car) to injuries from falling objects (hammer, wooden beam, ceiling) to
the final cases, nos. 28 to 33, which report consequences of injuries from machine
work (left arm, right hand, left calf, right hip). Railway spine comes first because its
existing case-discourse opens the category, which is then revised and extended to the
industrial world in general. In the monograph the same cases are cited, but ordered by
psycho-pathological symptom category: psyche, reflex, motor, vegetative. Running
reference to case number zippers symptom series to trauma series. In short, where
the sequence of Louis’s cases logically demonstrated a disease caused and defined by
a lesion, the sequence of Oppenheim’s cases and its recombination delineated
a new disease caused by a new world.
From Fritze through Louis to Oppenheim, we have traversed a century of seri-
ality the century of disease series and their crucial role in constituting clinical
knowledge.
If the marking, extracting, and formatting paperwork in these cycles of selective
reading seems trivial, consider that such a recursive procedure had to happen fast,
virtually all at once. For it depended on the reader’s memory as much as on what was
on the page. In order to compare, include, and exclude cases, many texts had to be read
in effect at the same time, which meant in practice, since reading is linear, remem-
bered. And since memory is limited, this in turn meant condensing and formatting
to enable the all-in-one-view that tables were supposed to provide.
53
Thus structured
and stocked, the mind was not a memory palace but an indexed bureaucratic register.
5. THE SERIES ACCORDIONED
Psychiatry and pathology aside, what happened to all this with the rise of the
laboratory and of wood, glass and metal not paper technology in medicine:
stethoscope, microscope, clinical thermometer, kymograph and other graphical
recording devices?
54
Was the practice we describe not rendered obsolete or marginal
304 · VOLKER HESS AND J. ANDREW MENDELSOHN
by these instruments and by increasingly laboratory-based knowledge and ways of
knowing?
55
That was certainly the intent. In the 1840s a new generation the likes of Virchow,
Jacob Henle, and Hermann Helmholtz in Germany, and Claude Bernard in France
began working to refound knowledge of sickness and health on experimental
science. Even young clinicians such as Carl Wunderlich led this new programme,
aiming to apply exact measuring and quantitative methods to medicine. Wunderlich
and Wilhelm Roser founded the first of the programmatic medical scientific journals.
Clinical medicine, they charged, was preoccupied by inexact disease pictures and by
false disease types or “ontologies”. The problem was less that the clinical pictures
were inexact and the disease types wrong than that both were wrong-headed: not
how to ground knowledge and treatment in science. So Wunderlich aimed to purge
them from medicine in the 1840s. He ended up in the 1860s doing the opposite:
establishing disease types on the basis of a new way of picturing disease that would
structure medical recording for the next 100 years: the fever curve (Figure 5). Paper
technology, to put it bluntly, made him do it. That is, paper technology in its admin-
istrative form and hospital matrix.
The clinicians presented the method of the fever curve as a laboratory revolution
in medicine. A method developed in laboratories, the so-called graphic method,
56
was, they claimed, not only applied in the clinic — to patients rather than animals
but remade the clinic as laboratory science: exact and quantitative, controlled and
explanatory, if not experimental. In fact, however, the method of the fever curve sprang
not from the laboratory but from the hospital — from exactly the history told here.
This can be seen in three ways. First, the continuity of observation. As early as the
1770s, reform-minded physicians touted the hospital as the only institutional setting
within which the Hippocratic ideal of continuous observation could be realized. Its
daily routines and standards across all beds could keep observers captive “forced
by their position” — and observations “regular”.
57
And in some eighteenth-century
hospitals this ideal was realized, as we witnessed in de Haen and his assistants’
recording of the pulse and other signs every two hours. The fever curve would have
been impossible under other conditions. Integrated into daily ward routine in mid-
nineteenth-century Leipzig (as well as in Berlin, Basel and elsewhere), graphical
charts took over the recording and labour-organizing functions of tabular journals.
Millions upon millions of measurements — temperature, pulse, respiration — were
made and graphed by doctors and nurses following the strict routines.
Second, the patient’s entire illness as unit of knowledge. The documentation of
disease in the hospital, as in medical practice generally, was built around the patient’s
illness as a whole, not some one aspect of it as could be singled out in the laboratory.
The fever curve did indeed privilege one sign, body temperature, but as indicator of
the whole, of what Wunderlich came to call the “constitution” and “total organism”
of the patient, a holistic language contrasting starkly with the language of exact,
analytical science as he himself had used it. Moreover, the documentation of disease
in the hospital was built around the entire clinical course, the days of sickness (dies
CASE AND SERIES · 305
Fig. 5. Specific temperature curves of typhus and typhoid fevers. From C. A. Wunderlich, Das Verhalten
der Eigenwärme in Krankheiten (Leipzig, 1868).
306 · VOLKER HESS AND J. ANDREW MENDELSOHN
morbi) from the start before admission (with the history-taking) to the end in cure
or death, rather than some segment of it. Clinical course, or Verlauf, was a key title
word in the stream of publications from Wunderlich and his assistants. Hospital
routine and recording captured this where practice casebook would often note only
key moments and sequences of treatment and effect.
Third, separation of features and singling out of one. The reordering of the patient
history into a graphical chart organized along the fever curve was one more step in
the tabulation of the patient that began, as we saw, in the late eighteenth century. As
in the tabular register — explicit in Siebold’s surgical clinic, implicit in the cases de
Haen published from the Vienna clinic, presented as a tool in the Tableau of Pierre
Louis the fever chart converted heterogeneous descriptive prose into lines of
homogeneous selected features.
Even the actual practice of plotting and connecting data points — unlike experi-
mental physiology’s graphic method in which there were no data points, only the
curve produced by the stylus already belonged to contemporary routines of medical
observation. In the century before 1850, these routines had come to include measure-
ment of temperature once or even thrice daily temperature not of the body but
of the air. Hospitals and medical faculties required trainees to make these and other
parallel, health-relevant meteorological measurements and record them in tabular
registers.
58
Tables yielded to graphs by the 1820s. Monthly weather curves began
appearing in, for example, Christoph Wilhelm Hufeland’s widely circulating Journal
der practischen Heilkunde, which also urged the reader to make his own using graph
paper available cheaply in a bookshop for “3 silver pennies apiece”.
59
Such were the
conditions under which the hospital practice of plotting and drawing fever curves
could continue the hospital practice of plotting and drawing weather curves. And these
were the conditions under which the ideals and rhetoric of exact laboratory science,
of experimental physiology’s graphic method, could be appropriated for clinical
science. The point here is that the lab did not “impact on” the clinic; the relevance
of its ideals had to be created in the clinic. And this happened inadvertently through
the emergence of the hospital as a highly ordered, administrated, disease-tabulating,
paper-inscribing space of knowledge.
More important than how fever curves were produced and what made them pos-
sible was what was done with them, how they were used in making knowledge. Thus
whereas both the developers and the historians of the graphical method emphasized
epistemology (self-registering instruments, objectivity), the important issue in the
history of the fever curve is instead ontology (making the general out of the particular,
types). This too was a product of paper technology in the hospital, not of mathematical
or laboratory science or indeed any other intellectual or practical context.
What could be done with a curve? With a single curve, features such as changing
slope could be analysed using geometrical reasoning to reach conclusions about the
causes of the behaviour being plotted; or the laws of such behaviour could be derived
by fitting mathematical functions to the curve.
60
And toward such ends, a single general
curve could in principle have been produced: average the thermometer readings from
CASE AND SERIES · 307
all patients at each measurement time on Day 1, on Day 2, and so on, and then plot
those averages over time. But Wunderlich and his contemporaries practised neither
statistical method nor geometrical analysis or mathematical function-fitting. What
did they do instead? In the absence of relevant manuscripts, a rare glimpse of exactly
how they did forge case curves into general knowledge can be had from a paper
61
published by Max Friedländer in 1867. These are the charts of five patients diagnosed
with cholera (Figure 6). Friedländer aimed to determine the typical course of fever
in cases of cholera. To do so, he cut and pasted curves into series. The published
five-curve example presents one moment in a continuous and self-adjusting process
of extracting, juxtaposing, comparing, sorting and re-sorting curves — cases into
series. This series of cases looks completely different from those we have so far seen:
Fritze, Oppenheim, Louis. But beneath appearances, its structure and production are
the same — and equally derivative of paper technology in the hospital.
How so? The curves are a better table. This can be seen in both their form and their
effects. In form: like tabulated illnesses, these plotted illnesses are stackable. Unlike
a narrative case history, each curve is a potential row. Why? Because plotting data
on graph paper is equivalent to entering data into columns: each procedure extracts
only one or a few homogeneous elements from the heterogeneity of the patient his-
tory and puts these elements into the same horizontal order on the page, whether in
columns by organ or, on graph paper, in columns by time of illness (Day 1, Day 2,
…). Looking beyond the fever curve on the chart, its closeness to the table becomes
still more obvious in the two rows of pulse and respiration rates. The effect, too, is the
same as that of the table: the stacked curves permit the eye to take in their similarities
and differences in one view and, on this basis, to sort and re-sort them according to
those similarities, yielding in the end a synthesis without statistics and despite
the fact that what is being synthesized is quantitative. In short, although they dealt in
numbers rather than words, these mid-nineteenth-century clinicians did exactly what
the long, slow previous history of paper technology in the hospital would predict:
they treated numbers and graphs just as they treated written bedside or postmortem
observations. They turned patterns of numbers into types, clinical pictures. And they
did so via graph paper, that is, via a tabular, reducing, homogenizing, standardizing
organization of patients’ illnesses into series of cases.
The one difference was nonetheless an important one: the series disappeared.
Stacked, the curves accordioned together into a single curve, a type curve (see Figure
5), and unlike Fritze, Louis, and Oppenheim, Wunderlich published no series of
cases. This was the advantage of curves over tables in the generation of the general
out of particulars. The clinicians described this process only abstractly, indeed as
abstraction. But abstraction had concrete, paper underpinnings. With Friedländer’s
juxtaposed curves in mind, its practice can be imagined along the lines of Francis
Galton’s composite photographic portraits.
62
Only here it was the long exposure of
a new clinical eye to thousands of curves that layered them into a serial composite.
In short, although an x/y axis coordinate system is an ordering of data very dif-
ferent from tables of rows and columns, and although fever curves would seem to
308 · VOLKER HESS AND J. ANDREW MENDELSOHN
Fig. 6. Making the accordioned fever curve from five case curves. From Max Friedländer, “Ueber den Zutritt der Cholera zu fieberhaften Krankheiten”, Archiv der
Heilkunde, viii (1867), 439–48 (fever curves in the appendix to this volume).
CASE AND SERIES · 309
take us into a different history of paper technology, in fact they did not. They were
a new and more powerful version of the same paper technology, with its operations
of formatting, extracting, listing. The production of general fever curves in the foun-
dational years of “scientific medicine [wissenschaftliche Medizin]” was determined
neither by ideals and practices of exact, quantitative science nor by the introduction
of an instrument, the rise of clinical thermometry. It was instead scripted by the
century-long story told here.
Administrative paper practice overrode scientific programme even the programme
of science in the dawning age of the laboratory. Wunderlich and his fellow pioneers of
“physiological medicine” famously aimed to explain each bedside observation using
“anatomical, chemical, and physiological facts” won in the laboratory, rather than to
synthesize bedside observations into a non-explanatory if general clinical picture.
63
They ended up doing precisely the latter and not the former. This meant, moreover, that
they ended up achieving the aims of the earlier, “natural-historical school” of German
medicine which they had derided and defined themselves against.
64
Wunderlich’s typical
fever curve defined typhoid for the German physiological school just as Pierre Louis’s
constant lesion (ulcerated Peyers patches) defined typhoid for the Paris school both
for no theoretical reason. Each was the unexplained and non-explanatory result of the
same generic, administrative paper technology, brought to bear on disease through a
hundred-year development of the hospital. Paper technology redefined disease without
theory, across seemingly fundamental “school” divides, and contrary to actors’ original
intents and revolutionary scientific programmes. Thus, we propose, should the his-
tory of medical science be periodized not, as usually, according to clinical (“Paris”)
and laboratory revolutions and “schools” such as these, but according to the knowing
practices that transcended and overrode such differences.
The new, “physiological” physician was supposed to make judgements around
“each pathological fact” rather than something so abstract and inexact as a type
of disease or clinical course and, moreover, to ground those judgments in “exact
knowledge of the anatomical and functional nature [Verhältnisse] of the relevant
parts” of the body the parts not the whole.
65
This entire proposed mode of medical
knowing and practising was eventually contradicted by its articulators’ own serial
composition of general fever curves.
66
These were pathological types (“the type
abstracted out of uncomplicated cases of the disease form in question”
67
) rather than
pathological facts; abstract and synthetic rather than exact. And they were “fashion-
ings of the clinical course”,
68
knowledge of wholes, not parts. The individuality of
the patient disappeared into the general, but the temporal wholeness of the patient
history survived, oddly, in the reduced and quantitative form of a line on a page, the
curve. This was not because the clinicians retained some holistic bent against the
reductive, analytic laboratory and dissection room. (Analytic exact science belonged
not to a laboratory movement but to all renewers of the science of medicine in the
mid-nineteenth century, not least clinicians like Wunderlich.) The individual curves
were (temporal) wholes because they were patient records. And the paper-technology-
driven process of knowledge-making preserved that form: the general retained the
310 · VOLKER HESS AND J. ANDREW MENDELSOHN
form of the particular. Thus medical knowledge took the form of the patient record:
it was a general patient record.
6. CONCLUSION
Not just any repeated activity of observation or notation yields more than its own
chronology. Not just any putting one thing after another makes a conclusive sequence.
To be knowledge-productive, a series must sum — its elements reduced and homo-
geneous enough to be commensurable and be more than the sum of its parts.
Our examples show this difference. And, strikingly, the difference turns out to be
historical: a difference between mere chronology of experience (Fabry’s centuriae)
or stringing together of beads in all shapes and sizes and no particular order (num-
bered sequences of observationes in Bonet’s topoi) in the seventeenth century and
the series of ‘observations’ generated later by the activities we met in Fritze, Louis,
and Oppenheim and their hospital milieux. One could imagine weaker evidence for
the proposition that knowledge-productive series seriality emerged over a
particular time in history.
The transition from the one to the other occurred through the use of certain tech-
niques. The construction of series (and all the ordering we have described) was not
a function of experience, but it was an empirical activity on paper. Its techniques,
unlike chemists’ structural formulae or physicists’ diagrams or other paper tools
designed for special scientific tasks, belong to expansive histories.
How far did paper technology drive medicine? The question is of course meant
provocatively.
69
No new paper technological determinism — ‘hard’ or even ‘soft’
should replace an old one of glass, wood, and metal devices.
70
Throughout we have
stressed equally the social shaping of paper technology:
71
first by the culture and
practice of learning and the book, then by the culture and practice of administration.
Still, one may wonder how important it was. There is no universal answer to this
question. Our last example showed paper technology and in and through it, modern
administration and work organization — regnant: more powerful than programmes
of laboratory revolution in shaping what and how physicians knew;
72
more determin-
ing than instruments of glass and metal; quietly overriding differences and conflicts
between “schools” and even the intentions of its users. Our first examples showed
medicine in the seventeenth century already in possession of thousands of sometimes
detailed patient histories. What was done with them and how is, we suggest, the key
to understanding three formative centuries of modern medical knowledge.
73
REFERENCES
1. See Karl Deichgräber, Die Epidemien und das Corpus Hippocraticum: Voruntersuchungen zu einer
Geschichte der koischen Ärzteschule (Berlin, 1933); Kathryn Montgomery Hunter, Doctors’
stories: The narrative structure of medical knowledge (Princeton, 1991).
2. For other answers, see J. Andrew Mendelsohn, “The world on a page: Making a general observation
in the eighteenth century”, in Histories of scientific observation, ed. by Lorraine Daston and
Elizabeth Lunbeck (Chicago, 2010).
CASE AND SERIES · 311
3. Ursula Klein, Experiments, models, paper tools: Cultures of organic chemistry in the nineteenth
century (Stanford, 2003); Andrew C. Warwick, Masters of theory: Cambridge and the rise of
mathematical physics (Chicago, 2003); David Kaiser, Drawing theories apart: The dispersion
of Feynman diagrams in postwar physics (Chicago, 2005). A classic on tools for purposes is
Adele E. Clarke and Joan H. Fujimura, The right tools for the job: At work in twentieth-century
life sciences (Princeton, 1992).
4. For case histories, see Johanna Geyer-Kordesch, Medizinische Fallbeschreibungen und ihre
Bedeutung in der Wissensreform des 17. und 18. Jahrhunderts”, Medizin, Gesellschaft und
Geschichte, ix (1990), 7–19; for historia, Gianna Pomata, “Praxis historalis: The uses of historia
in early modern medicine”, Historia: Empiricism and erudition in early modern Europe, ed. by
Gianna Pomata and Nancy G. Siraisi (Cambridge, MA and London, 2005), 105–46.
5. See for instance Johannes Schenck von Grafenberg, Observationes medicae de capite humano: hoc
est, exempla capitis morborum, causarum, signorum, eventuum, curationum, ut singularia,
sic abdita et monstrosa. Ex claris. medicorum, veterum simul & recentiorum scriptis / à Io.
Schenckio, de Grafenberg ... collecta (Basel, 1584); Felix Platter, Observationum, in hominis
affectibus plerisque, corpori et animo, functionum laestione, dolore, aliave molestia et vitio
incommodantibus, libri tres ... accommodati. In quibus eo ordine, diversorum affectuum sub
generibus hisce comprehensorum, progressus, eventus, curationes ... historice describuntur (Basel,
1614); Théophile Bonet, Sepulchretum sive anatomia practica ex cadaveribus morbo denatis
(Geneva, 1679); Giovanni Battista Morgagni, Epistolae anatomicae duae novas observationes,
et animadversiones complectentes. Quibus anatome augetur, anatomicorum inventorum historia
evolvitur, utraque ab erroribus vindicatur : adjectus est, index rerum, et nominum accuratissimus
(Venice, 1762).
6. Wilhelm Fabricius Hildanus, Observationum & curationum chirurgicarum centuriae: in qua inclusa
sunt viginti & quinque, antea seorsim aeditae reliquae nunc cum nonnullis instrumentorum, ab
autore inventorum delineationibus, in gratiam & vtilitatem artis Chirurgicae in lucem prodeunt;
Cùm Indice (Basel, 1606); idem, [Observationes et curationes cheirurgicae] Guilhelmi Fabricii
observationum et curationum cheirurgicarum centuria secunda : epistolis nonnullis virorum
doctissimorum, nec non instrumentis cheirurgicis / ab authore inventis illustrata (Geneva,
1611); idem, [Observationes et curationes chirurgicae] Guilhelmi Fabricii observationum et
curationum chirurgicarum centuria quinta: epistolis virorum doctorum, nec non instrumentis
/ ab autore inventis illustrata (Frankfurt, 1627); idem, Opera observationum et curationum
medico- chirurgicarum quae extant omnia (Frankfurt/Main, 1646).
7. Ann Blair, “Humanist methods in natural philosophy: The commonplace book”, Journal of the
history of ideas, liii (1992), 541–51; Helmut Zedelmaier, Bibliotheca universalis und bibliotheca
selecta: Das Problem der Ordnung des gelehrten Wissens in der frühen Neuzeit (Cologne, 1992),
70–5; Ann Blair, “Reading strategies for coping with information overload ca. 1550–1700”,
Journal of the history of ideas, lxiv (2003), 11–28; Lars Behrisch, “Zu viele Informationen!
Die Aggregierung des Wissens in der Frühen Neuzeit”, Information in der Frühen Neuzeit :
Status, Bestände, Strategien, ed. by Arndt Brendecke, Markus Friedrich and Susanne Friedrich
(Berlin, 2008), 455–73.
8. The index to the first Centuria (1606) contains only one entry for “Gangraena” (see below), in contrast
to six entries in the Opera (ref. 6).
9. Fabry, Opera (ref. 6), Index.
10. Zedelmeier, Bibliotheca (ref. 7).
11. Karl Ernst Georges, Lateinisch-Deutsches Handwörterbuch (2 vols, Leipzig, 1855), i, 1951.
12. Gessner cited in Zedelmeier, Bibliotheca (ref. 7), 88.
13. Wilhelm Fabricius Hildanus, Observationum et epistolarum chirurgico-medicarum centuriae in
certum ordinem digestae ed. a Johanne Sigismundo Henningero (2 vols, Strasbourg, 1713–17).
312 · VOLKER HESS AND J. ANDREW MENDELSOHN
14. Helmut Zedelmaier, Facilitas inveniendi: Zur Pragmatik alphabetischer Buchregister,
Wissenssicherung, Wissensordnung und Wissensverarbeitung: Das europäische Modell der
Enzyklopädie, ed. by T. Stammen and W. E. J. Weber (Berlin, 2004), 191–203, p. 201.
15. Fabry, op. cit. (ed. Henninger) (ref. 13), i.
16. Observatio 19 in Centuria VI (ref. 6).
17. Fabry, op. cit. (ed. Henninger) (ref. 13), ii: Index.
18. Arndt Brendecke, Tabellen und Formulare als Regulative der Wissenserfassung und
Wissenspräsentation”, Autorität der Form — Autorisierung Institutionelle Autorität, ed. by
Wulf Oesterreicher, Gerhard Regn and Winfried Schulze (Münster, 2003), 37–53, p. 37, for the
early example of Charles V’s questionnaire on the American colonies. On questionnaires and
their problems circa 1800, see Marie-Noëlle Bourguet, Déchiffrer la France: La statistique
départementale à l’époque napoléonienne (Paris, 1989).
19. For Württemberg, Baden, Saxony, Switzerland, and the Habsburg lands, see Lars Behrisch, “‘Politische
Zahlen’: Statistik und die Rationalisierung der Herrschaft im späten Ancien Régime”, Zeitschrift
für Historische Forschung, xxxi (2004), 551–77; for France, Christine Lebeau, “Vom Raum der
Verwaltung zum Raum des Gelehrten: Il Governo della Toscana sotto il Regno di Sua Maestà il
Re Leopoldo II (1790)”, Vermessen, Zählen, Berechnen: Die politische Ordnung des Raums im
18. Jahrhundert, ed. by Lars Behrisch (Frankfurt/Main, 2006), 131–49; for England and France,
Andrea Rusnock, Vital accounts: Quantifying health and population in eighteenth-century
England and France (Cambridge, 2002).
20. Quoted in Otto Behre, Geschichte der Statistik in Brandenburg-Preussen bis zur Gründung des
Königlichen Statistischen Bureaus (Berlin, 1905), 373.
21. Christian Probst, Der Weg des ärztlichen Erkennens am Krankenbett: Herman Boerhaave und die ältere
Wiener medizinische Schule, i: 1707–1787 (Wiesbaden, 1972); Guenter B. Risse, Hospital life
in Enlightenment Scotland: Care and teaching at the Royal Infirmary of Edinburgh (Cambridge,
1986); Johanna Bleker, Eva Brinkschulte, and Pascal Grosse, Kranke und Krankheiten im
Juliusspital zu Würzburg: Zur frühen Geschichte des Allgemeinen Krankenhauses in Deutschland
(Husum, 1995).
22. Adding columns for medical observations: Joseph Michel Dulaurens, Essai sur les établissemens
nécessaires et les moins dispendieux pour rendre le service des malades dans les hôpitaux
vraiment utile à l’humanité (Paris, 1787), chap. 9.
23. Johann Georg Christoph Siebold, Vorläufige Nachricht von der gegenwärtigen Einrichtung des
Klinikums an dem Julius-Hospital zu Würzburg unter Aufsicht des Professors Siebold des ngeren:
Nebst einigen allgemeinen Bemerkungen über Spitäler und klinische Anstalten in akademischer
Hinsicht (Würzburg, 1795), quotation on p. 14.
24. In Berlin a report “according to the pre-set schema” was to be written and then examined (Instruction
r die drey Pensionair-Chirurgi und den Stabs-Chirurgus in der Charité (1799), §10,
Universitätsarchiv der HU Berlin (UAHU), Charité-Direktion 1725–1945, no. 173a, 96–98).
For Vienna, see the example of de Haen below. See also the scheme presented by Johann Peter
Frank, “Entwurf zur Einrichtung einer klinischen Schule”, in his Drey zum Medicinalwesen
gehörige Abhandlungen (Leipzig, 1794), 1–36, pp. 34f.
25. Siebold, Nachricht (ref. 23), 11.
26. Anton de Haen, Ratio medendi continuitata seu operum posthumorum (Vienna, 1789), 3–24, p. 8.
27. Johann Friedrich Fritze, “[Bericht]”, Annalen des klinischen Instituts zu Berlin, i (1792), 1–130, p. 10.
28. Ernst Horn, Oeffentliche Rechenschaft über meine zwölfjährige Dienstzeit als zweiter Arzt des
Königlichen Charité-Krankenhauses zu Berlin (Berlin, 1818), 17. In Würzburg, departing clinical
trainees had to relinquish their journals (Siebold, Nachrichten (ref. 23), 37).
29. Fritze, “Bericht” (ref. 27), 10.
CASE AND SERIES · 313
30. Thomas Sydenham, Observationes medicae circa morborum acutorum historiam et curationem
(London, 1676).
31. Fritze, “Bericht” (ref. 27), 12–15.
32. Ibid., 41.
33. Ibid., 10; table on p. 8.
34. Pierre Charles Alexandre Louis, Recherches anatomiques, pathologiques et thérapeutiques sur la
maladie connue sous les noms de gastro-entérite, fièvre putride, adynamique, ataxique, typhoïde,
etc.; comparée avec les maladies aiguës les plus ordinaires (Paris, 1829).
35. Ibid., i, 29.
36. Ibid., i, 62.
37. Ibid., i, 105.
38. Gérard Jorland, “La médecine statistique du Docteur Louis”, Les thérapeutiques: Savoirs et usages,
ed. by Olivier Faure (Lyon, 1995), 123–33; Ann La Berge, “Medical statistics at the Paris
School: What was at stake”, Body counts: Medical quantifications in historical & sociological
perspectives, ed. by Gérard Jorland, Annick Opinel and Georg Weisz (Montreal, 2005), 89–108.
39. See Mendelsohn, “World” (ref. 2); J.-J. Leroux, Commission de l’Instruction publique : Académie
de Paris : Faculté de médecine – Clinique interne : Société d’instruction médicale : réglement
(Paris, 1818).
40. Pierre Charles Alexandre Louis, “De l’examen des malades et de la recherche des faits généraux”,
Mémoires de la Société Médicale d’Observation, i (1837), 1–63.
41. Louis retains this common tripartite division in the autopsy results published in the book.
42. Examples can be found in the Archive of the Charité Morgue, Berliner Medizinhistorisches Museum.
43. To which chief symptoms have been added, though it is unclear exactly when and how selected.
44. Volker Hess, “Raum und Disziplin: Klinische Wissenschaft im Krankenhaus”, Berichte zur
Wissenschaftsgeschichte, xxiii (2000), 317–29.
45. UAHU (ref. 24), no. 48 (Anschaffung von Formularen, Drucksachen, Schreibmaterialien), p. 2; and
no. 75 (Nachweisung über Drucksachen und Schreibmaterialien), p. 8.
46. Ingo Wirth, Quellenband zur Sektionstätigkeit im Pathologischen Institut der Friedrich-Wilhelms-
Universität zu Berlin von 1856 bis 1902: Ein Beitrag zur Virchow-Forschung (Berlin, 2005).
47. Volker Hess and Eric J. Engstrom, “Neurologie an der Chari zwischen medizinischer und
psychiatrischer Klinik”, Geschichte der Neurologie in Berlin, ed. by B. Holdorff and Rolf Winau
(Berlin, 2001), 100–10.
48 Bandakten der Poliklinik, 1888–1891, Historisches Psychiatriearchiv, Institut für Geschichte der
Medizin, Berlin.
49. Berliner Medizinhistorisches Museum, Archive of Charité Morgue: see, for example, Protokollbuch
1864.
50. Hermann Oppenheim, Die traumatischen Neurosen nach den in der Nervenklinik der Charité in
den 8 Jahren 1883–1891 gesammelten Beobachtungen, 2nd edn (Berlin, 1892); see also idem,
“Weitere Mittheilungen über die sich an Kopfverletzungen und Erschütterungen (in specie:
Eisenbahnunfälle) anschliessenden Erkrankungen des Nervensystems”, Archiv r Psychiatrie und
Nervenkrankheiten, xvi (1885), 743–77; Georg Güth, Über den diagnostischen Werth einzelner
Symptome der traumatischen Neurose (Diss. med., Berlin, 1890).
51. Heinz-Peter Schmiedebach, Psychiatrie und Psychologie im Widerstreit: Die Auseinandersetzung in
der Berliner medicinisch-psychologischen Gesellschaft (1867–1899) (Husum, 1986), 144–51;
Ruth Kloocke, “Psychological injury in the two World Wars: Changing concepts and terms in
German psychiatry”, History of psychiatry, xvi (2005), 43–60.
52. For instance, Beobachtung I in Oppenheim, Mittheilungen is re-used in its entirety as
“Beobachtung XV” in Oppenheim, Neurose; no. II in “Mittheilungen” is no. VI in Neurose and
314 · VOLKER HESS AND J. ANDREW MENDELSOHN
no. I in Güth, Werth (ref. 50).
53. See, for example, Dictionnaire de l’Académie Française (1694), s.v. table: “tout d’une veuë”.
54. Stanley Joel Reiser, Medicine and the reign of technology (Cambridge, 1977).
55. See Andrew Cunningham and Perry Williams (eds), The laboratory revolution in medicine (Cambridge,
1992); John Pickstone, Ways of knowing: A new history of science, technology, and medicine
(Chicago, 2000).
56. Richard L. Kremer, “Building institutes for physiology in Prussia, 1836–1846: Contexts, interests
and rhetoric”, The laboratory revolution in medicine, ed. by Cunningham and Williams (ref. 55),
72–109; Soraya de Chadarevian, “Graphical method and discipline: Self-recording instruments
in nineteenth-century physiology”, Studies in the history and philosophy of science, xxiv (1993),
267–91; Robert M. Brain, “Representation on the line: Graphic recording instruments and
scientific modernism”, From energy to informatics: Representation in science and technology,
art, and literature, ed. by Bruce Clarke and Linda Dalrymple Henderson (Stanford, CA, 2002),
155–77.
57. M. Chambon de Montaux, Moyens de rendre les hopitaux plus utiles a la nation (Paris, 1787), 150.
58. Leroux, Commission (ref. 39); Peter Krukenberg, Entstehung, Einrichtung und Fortgang der
ambulatorischen Klinik zu Halle”, Jahrbücher der ambulatorischen Klinik zu Halle, 1820, 1–43.
59. Christoph Wilhelm Hufeland, “Bildliche Darstellung des Barometer- und Thermometerstandes der
Monate Januar, Februar, März dieses Jahres”, Journal der practischen Heilkunde, liv (1829), 127f.
60. For such reasoning around epidemiological curves, see Victor L. Hilts, “Epidemiology and the
statistical movement”, Times, places, and persons: Aspects of the history of epidemiology, ed.
by Abraham M. Lilienfeld (Baltimore and London, 1980), 43–55.
61. Max Friedländer, “Ueber den Zutritt der Cholera zu fieberhaften Krankheiten (Fieberkurve im
Anhang)”, Archiv der Heilkunde, viii (1867), 439–48.
62. Francis Galton, “Composite portraits”, Journal of the Anthropological Institute, viii (1878), 132–42.
63. Wilhelm Griesinger, “Bemerkungen zur neuesten Entwicklung der allgemeinen Pathologie”, Archiv
für physiologische Heilkunde, ii (1843), 278–89, p. 283.
64. Johanna Bleker, Die Naturhistorische Schule 1825–1845: Ein Beitrag zur Geschichte der klinischen
Medizin in Deutschland (Stuttgart, 1981).
65. W. Roser and C. A. Wunderlich, “Ueber die Mängel der heutigen deutschen Medicin und ueber
die Nothwendigkeit einer entschieden wissenschaftlichen Richtung in derselben”, Archiv für
physiologische Heilkunde, i (1842), pp. i–xxx, p. ii.
66. The unwilling Wunderlich: even as he took over the St Jakob Hospital in the 1850s, he remained
at first sceptical about temperature measurements and it was his assistants who did this work
and published on it: Volker Hess, Der wohltemperierte Mensch: Wissenschaft und Alltag des
Fiebermessens (1850–1900) (Frankfurt/Main, 2000), 155.
67. C. A. Wunderlich, Das Verhalten der Eigenwärme in Krankheiten (Leipzig, 1868), 269.
68. Ibid., 271.
69. See Merritt Roe Smith and Leo Marx (eds), Does technology drive history? The dilemma of
technological determinism (Cambridge, MA, 1994).
70. The best introduction to the role of instruments in modern medicine remains Reiser, Technology
(ref. 54).
71. See the classic anthology: Donald A. MacKenzie and Judy Wajcman, The social shaping of technology,
2nd edn (Buckingham, 1999).
72. See Cunningham and Williams, Revolution (ref. 55).
73. It has not escaped our attention that the history outlined here suggests a new solution to the problem
of characterizing and explaining transformations still inadequately understood as “the birth of
the clinic”, revolutionary “Paris medicine”, or the rise of “hospital medicine”.
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