Vital Signs: The Transformation of the Medical Record in Nineteenth Century America
John Harley Warner, PhD, Yale School of Medicine
Between the early nineteenth century and the start of the twentieth, the hospital patient record was transformed. Drawing on surviving manuscript patient charts and focusing on the United States, I first trace how a discursively rich record was supplanted by one that expressed narrative preferences for precision and exactitude, quantification and visualization, impersonality and detachment, uniformity and standardization, and an aspiration to universalism. In the process, the textual presence of the individuated sick person and the individual physician all but vanished, part of a larger program to eradicate “the personal equation” of doctor and patient alike. I then explore the epistemological, technical, and moral choices at work in shaping this modern medical case record and how the new version of scientific medicine that the experimental laboratory emblemized brought a new aesthetic preference to the clinical practice of writing. This transformation took part in making and expressing a new kind of professional identity, reshaping clinicians’ conceptions both of patients and of themselves—with lasting biomedical and human consequences. I close by looking at efforts early in the twentieth century to establish this model for clinical narrative as the American norm and at clinicians’ anxieties about what was being lost—or placed at risk of being lost—in the process, part of a broader impulse to reenchant the art of healing in an age of medical science.
Panel I: The Medical Record & New Media
Computerizing Diagnosis: Keeve Brodman and the Medical Data Screen
Andrew Lea, Doctoral Candidate, University of Oxford
In 1947, the Cornell psychiatrist Keeve Brodman and a handful of colleagues began developing what would become one of the most widely used health questionnaires of its time—the Cornell Medical Index (CMI). A rigidly standardized form, the CMI presented 195 yes-no questions designed to capture the health status of “the total patient.” Over the following decades, Brodman’s project of standardizing medical history taking gradually evolved into a project of mathematizing and computerizing diagnosis: out of the CMI grew the Medical Data Screen (MDS), one of the first computerized methods of deriving diagnoses from patient data. At the same time Brodman was working to computerize medical diagnosis, other researchers at Cornell were envisaging ways of using the CMI to help automate medical history taking. These researchers proposed transferring CMI data onto IBM cards suitable for the Medical Center’s IBM 360/40 computer. The computer would then process this data, both converting the CMI inputs into “Summary Patient History” forms (which would be mounted directly on patients’ charts) and producing a “Permanent Patient Record” on the IBM magnetic disc packs (which would be available for high-speed retrieval). This paper discusses the ideas, questions, and challenges that Brodman and his colleagues encountered as they attempted to adapt a paper-based technology for novel electronic and digital media.
Panel II: Paper Infrastructures
How ‘Enlightened’ Physicians Read: Albrecht von Haller’s Bibliotheca Medica
Fabian Kraemer, PhD, Ludwig-Maximilians-Universität
The Swiss naturalist Albrecht von Haller (1708-1777) is mostly remembered for the important contributions to physiology that he was able to make between 1736 and 1753, when he was chair of medicine, anatomy, botany and surgery at the young University of Göttingen. His Bibliotheca medica, an impressive contribution to the thriving field of Historia litteraria (history of scholarship), is by comparison understudied. It was only upon his return to Switzerland following the resignation of his chair that he set out to write it. During his lifetime he managed to finish three parts of it: Bibliotheca botanica (1771-1772), Bibliotheca chirurgica (1774-1775) and Bibliotheca anatomica (1774-1777), each of which comprises two volumes. The forth part, which was meant to be an exhaustive Bibliotheca medicinae practicae, was edited and amended on the basis of von Haller’s manuscripts by the physician Joachim Diterich (or Dietrich) Brandis (1762-1846) and published posthumously in 1788. In toto, the Bibliotheca medica lists and comments upon about 50.000 titles, many of which are marked with a star indicating that they were contained in von Haller’s large private library. Two aspects of these works deserve our attention: first, they provide a window upon von Haller’s view on how the “sciences” develop over time. Second, they bespeak his take on how a naturalist ought to read. In my paper, I will discuss these related aspects of von Haller’s Bibliotheca medica and contextualize them with regard to other contemporary or earlier contributions to Historia litteraria.
“A wholly new kind of medical literature”: Print and the practice of collective investigation, 1880-1890
Alexander T. Moffett, MD, Doctoral Candidate, Johns Hopkins University
In a Presidential Address delivered at the annual meeting of the British Medical Association in 1880, the surgeon George Murray Humphry called upon members of the Association to gather together to collect the vast amount of clinical knowledge that failed to find its way into the books and journals of the profession. The movement that Humphry proposed—what would come to be called collective investigation—involved the production of cards formatted to document particular clinical encounters with specific diseases, the circulation of these cards among large numbers of medical men, and the collation and codification of the results.
A Collective Investigation Committee was formed by the British Medical Association in 1881 and in the years that followed it circulated tens of thousands of cards and collected thousands of clinical observations. Collective investigation spread from Great Britain to Germany and the United States and was ultimately practiced around the world at the local, national, and international level. It was, as one journal put it, “all the rage.”
Collective investigation was many things to many people. This paper traces one particular line of argument offered in support of collective investigation, that it made possible the production of a form of authorless knowledge. Proponents of collective investigation held that its collective component could correct for the personal equation of the individual physician and thus produce a kind of objective medical knowledge that was otherwise missing from the medical literature. At the same time, collective investigation could be seen as an attempt correct a more fundamental limitation of this literature, that concerning the trust that could be placed in it.
The circulation of medical knowledge within this period was defined both by the increasing importance of the journal article and by the increasingly ephemeral nature of the journal itself. The changing political economy of print produced an increasing degree of instability within the publishing world, as a consequence of which some questioned the capacity of the journal article to function as the basic element of medical knowledge.
Within the disordered world of medical publishing collective investigation was intended to produce a kind of parallel publishing process, one defined by a very different moral economy than that of conventional medical publishing. Moreover, this moral economy was thought to have important consequences not only for the circulation of the products of collective investigation, but for the potential that such products possessed for the formation of distinct medical publics.
Collective investigation was ultimately seen as more than just a means of knowledge production. It stood as well as an attempt to redefine the bonds of the medical profession, to form a different kind of medical public than that which could be assembled with the circulation of medical journals alone.
“The Fourth Estate in the Profession of Medicine”: The Evolving Status and Roles of the Medical Journal in the United States
Scott Podolsky, MD, Harvard Medical School
In 1907, the President of the American Medical Editors’ Association, then in its fourth decade, began his Annual Address by declaring that “the fourth estate in the profession of medicine is of importance equal if not superior to any of the other elements whose combination welds it into the most important factor in modern life.” Nearly a century later, the former editor-in-chief of the British Medical Journal could begin a less optimistic account: “Medical journals, which many imagine to be dull as telephone directories and twice as obscure, influence the lives of everybody – and not always for the better.” Historians have devoted volumes to the evolution of American medical research, practice, and education. Yet medical journalism, which provides the chief source of information about such evolution, and which has come to occupy a central role in both the social functioning of the field and the production and dissemination of medical research, has received scant historical attention.
Medical journals have not simply disseminated new knowledge about medical theory and practice. Instead, they have defined the scope of medical concern and knowledge; articulated norms for the profession; and served as vehicles for announcing, advancing, and advertising particular schools, fields, and positions. Along the way, for two centuries medical journals have on the one hand confronted challenges regarding the freedom from bias of both journals and their authors, manifesting as conflict-of-interest concerns with respect to both industry and sponsoring societies. On the other hand, they have confronted the sheer size, relevance, and utility of the medical literature itself, a challenge that persists today in an era of open access journals and online platforms for communication.
Panel III: Digital Infrastructures
Life at a Distance: Labours and Futures of mHealth in Rural Burkina Faso
Vincent Duclos, PhD, Drexel University
The number of mobile health (mHealth) projects implemented in low-and middle-income countries has doubled in the past five years. The proliferation of mHealth networks and systems reconfigures the way life is rendered amenable to knowledge and intervention, at a distance. This paper discusses these transformations by examining the case of MOS@N, a mHealth network implemented in the district of Nouna, in rural Burkina Faso. Drawing upon ethnographic material, I make two propositions. First, I suggest that MOS@N challenges the notion – often embedded in policy-making and project design – that mobile devices are fluid, neutral conduits for the circulation of data. In the everyday workings of MOS@N, making phones and data mobile requires great labors and expenditures. Also, in MOS@N media devices do not only carry symbols and meanings but actually shape connections and transform who/what is connected – thus pointing at an understanding of media as messy, unpredictable, and transformational. Secondly, MOS@N provides insight on problems of scale and replicability which have become central within the global (m)health world. It raises the question of whether an experimental ethos marked by improvisation and situated labor can lend itself to formalization – and thus lead to the predictable scaling of a network like MOS@N. Ultimately, the future of MOS@N and of similar mHealth projects is facing a conundrum: only out of fragile, messy connections do consistencies appear to emerge.
Health Communication, Data Visualization, Digital Intermediation: Tracking Zika Virus
Kirsten Ostherr, PhD, MPH, Rice University
The entry of the Zika virus into global awareness has been a highly visual and digitally intermediated phenomenon, characterized by conflicting origin stories, unpredictable narrative arcs, and highly fluid interplay between diverse sources of data and social contexts of interpretation. Zika infection is difficult to detect with the naked eye, but its most devastating effects are characterized by the distinctly visual iconography of microcephaly in newborn babies. This global phenomenon has activated familiar images of contagion, including disease maps, health workers in face masks spraying for mosquitoes, and doctors in white coats examining vulnerable patients in the global south. Yet Zika virus has also activated a distinct form of imagery, highly characteristic of 21st century life around the world, yet extraordinarily flat as a form of representation: imagery of people staring at screens, in particular, smartphone screens.
Epidemiology as a field of practice transforms data into narratives about disease outbreaks with sources (characters), vectors (cause and effect chains), and patterns of distribution (conflicts and resolutions). In the digital age of 21st century global health, the practices of datafication have rendered most aspects of daily life into commodified forms of meaning that can generate novel kinds of value when coupled with the right data analytics. The initial detection of Zika virus in Brazil was accelerated by the digital disease detection that emerged when infectious disease specialists began to communicate with each other through WhatsApp. These medical doctors already communicated with their patients through the social media platform, and their ability to rapidly circulate patient data to physician colleagues transformed the epidemiology of Zika virus in Brazil. This talk will explore how data visualization and narration of disease outbreaks functions through digital health platforms, with a special focus on concepts of privacy and sharing, visibility and invisibility, at the intersection of personal and global health data.
Viral Chatter: Epidemic Intelligence and Bio-Digital Communication
Robert Peckham, PhD, University of Hong Kong
This paper explores how a communications model of surveillance is being developed to track viral activity on the frontlines of disease emergence, particularly in Central Africa and East Asia where highly pathogenic viruses, such as HIV, Ebola, avian influenza H5N1, and SARS have spilled over from their natural reservoirs into human populations. The term “viral chatter” is borrowed from the world of espionage and describes the traffic of suspect viruses across species. Like intelligence operatives, virologists monitor the volume of intercepted communications in order to anticipate potential crisis events. In recent years the concept of “viral chatter” has been popularized by the virologist Donald S. Burke and his protégé Nathan Wolfe, founder of the San Francisco-based company Metabiota and the non-profit Global Viral (formerly the Global Viral Forecasting Initiative). The “viral chatter” approach to disease detection draws on different scales of communication analysis. While it involves the collecting and sequencing of viruses, it also makes use of geotechnologies (specifically GIS and GPS-enabled devices), web-based tracking programs, cloud storage, and big data analytics. As a closed-loop model, it calls for the development of a global communications infrastructure where systemic changes will trigger feedbacks, and through which viral data will flow from hotspots in developing countries to processing-hubs behind the lines. This paper examines the consequences of this multi-scalar use of communication as a tool for data collection and for the simultaneous elucidation of biological, social, and synthetic signaling pathways and interference processes: from eavesdropping on viral mutations, to wildlife tracking, interspecies interactions, to online data-processing. The paper concludes by considering the institutional and geopolitical contexts that are shaping this bio-digital cybernetics paradigm in disease prevention.
Panel IV: Ways of Writing, Ways of Knowing
A case between literature and medicine: Büchner’s Lenz
Yvonne Wübben, MD, PhD, Ruhr Universität Bochum
My paper deals with the case of the German poet Jakob Michael Reinhold Lenz (1751-1792) who suffered from a short episode of mental derangement in early 1778. It shows how the case travelled through various disciplines (psychiatry, neurology, literary studies) in the 19th and early 20th century, and how it was represented in different genres (account, characteristic, pathography, anecdote). A central role in the history of the case was played by the short prose text by the physician and literary author Georg Büchner (1813-1837), published in 1839. Büchner’s narrative not only presents the case from the poet’s own perspective by means of internal focalization; it also leaves the nature of the illness open. Interestingly, the “doubtful case” later triggered various attempts at retrospective diagnosis, which can be linked to the rise and fall of different nosologies. Thereby, the Lenz case illustrates the interconnection of genre, nosology, the use of narrative techniques and the materiality of the text.
Twice Told Tales: The Locked Room Mystery and The Medical Case Report
Lakshmi Krishnan, MD, PhD, Johns Hopkins University
The array of genres within medical narrative is extensive, from informal presentations on daily rounds and the so-called “SOAP” note, a workhorse of inter-physician communication, to the retrospective, often-encyclopedic discharge summary. But there is none more traditionally literary than the case history – a formal, stylized retelling of a tale of illness, its investigation, suspicions and evidences, and denouement. Like the detective story, the case history bears the tension of two narratives: that of the illness or crime and that of the enquiry and solution. These two genres are eternally bound together. The doctor and the detective descend from the hunter, the original creator of a narrative reconstructed based on clues. And both hunters of knowledge have their Urtexts – for medicine the case report, dating back to Hippocrates, for detection the unraveling of the crime, transcribed and transmogrified for public consumption in the form of the fictional detective story or the true crime account.
We have long considered crime fiction a narrative camera obscura. For example, the “locked room mystery,” a sub-genre arguably originated by Edgar Allan Poe in 1841’s “The Murders in the Rue Morgue,” and continued by nineteenth century successors Gaston Leroux (“The Mystery of the Yellow Room”) and Arthur Conan Doyle (“The Adventure of the Speckled Band”) into the inter-war Golden Age detective story with Agatha Christie’s “And Then There Were None,” offers through its physical limits – a crime committed in a closed space with a finite number of possibilities – a reflexive and enclosed process of interpretation and a commentary on the nature of narrative itself.
But despite its narrative preoccupations, its “double plot” and self-consciously stylized production, the medical case report (unlike the detective story) has not been closely studied for its generic properties. It is generally viewed as a way of conveying information, a pedagogical tool, or the fundamental unit of clinical knowledge. Yet, during the early years of modern medicine, the physician was framed as a medical detective, with the pathologist who performed the autopsy uncovering the obscure narrative, the true tale of the disease, revealed only after death. The case report developed its own style in contrast to the popular mystery: self-consciously stark, relatively purged of tension or suspense. Unlike the locked room tale which enjoys its own obscurity, presenting the problem in a fog, the medical case report is usually diligently linear, direct, clear even when the solution is unclear.
The episteme of the case is the science of knowing, of acquiring full comprehension by means of incomplete information. More, the narrative itself contributes to this knowing. I argue that it is in the narrative reconstruction that the medical case report grapples with the uncertainty of knowledge, signposts forms of interpretation, and weighs the relative probabilities of solutions. Further, though detective fiction has morphed into many media forms, including the television forensic drama, the serial podcast, even the participatory “escape room,” a live action interaction with a scripted mystery, the medical case report has remained relatively unchanged since the ancients. It is useful to examine why that may be, for as we enter yet another era in modern medicine, one wonders whether it will –despite new technologies and workforce changes—remain so.
Panel V: New Media and Medicine
Genres of Mind and Moving Image
Carmine Grimaldi, Doctoral Candidate, University of Chicago
In the late sixties, an experimental psychiatric ward opened near the Haight Ashbury in San Francisco. Advertised as “a mix between a far-out school, a free-floating multi-media center, and an electronic therapeutic community,” the ward sought to cure young drug users through television, film and videotape. This talk will focus on the ways the clinic experimented with genres—how, for example, doctors adapted the talk show, the psychedelic video, and the art-house foreign film for new clinical purposes. Patients and doctors inhabited these templates, performed new roles, and watched themselves replayed on the screen. In this community, where the boundaries between an action and its representation became increasingly fluid, the genre became an instrument, a tangible and practical technique for psychological transformation.
Panel VI: Everyday Technologies
The Bathroom Scale and the Domestication of Surveillance
Deborah Levine, PhD, Providence College
This talk focuses on new anthropometric technologies employed by physicians and their patients in the late nineteenth century to measure the body and thereby construe a determination about health. Focusing especially on the history of one such technology—the bathroom scale—my aim is to explore the role of technology in the historical linking between maintaining “normal” weight and health that began to take hold in the 1860s and 1870s. Beginning with the the development of the freight scale at Howe Scale Company in Vermont, archival evidence demonstrates that Howe executives, initially uninterested in marketing smaller scales as anything more than a novelty, eventually developed ties with public health and actuarial professionals in order to market their product to the home consumer as a technology essential to health management. The talk then turns to the culture of measurements and measurers of American body weight, and begins to answer urgent questions for understanding notions of health, measurement, and the body during this period. This talk concludes with an examination of the weight measurement and subsequent health evaluations conducted by a key sector of American business in the early twentieth century: the life insurance industry. Actuarial data collected by life insurance companies during this period became the first widely circulated figures on population height and weight in relation to health in the United States. These became the guiding figures for a medical evaluation of weight-based American “national” health.
“Carrying therapeutic training into daily life situations: portable electromechanical device in behavior modification, 1970-1980”
Lucie Gerber, PhD, University of Strasbourg
In the mid-1970s, at Rockefeller University, behavioral psychologists Neal E. Miller and Barry D. Dworkin developed a “posture training device”. The device, tested on adolescents with scoliosis, was part of a decade-long effort to bring the principles and techniques of behavioral psychology to bear on an ever broader range of medical problems. This research program, carried out under the banner of biofeedback, had led Miller and his collaborators from the laboratory into clinical settings, from animal subjects to humans, and from stroke and accident patients to the less heterogeneous group of young girls in the early stages of idiopathic scoliosis. The latter were considered a better “model for the analysis of the applicability of instrumental learning to the treatment of skeletal-muscular disorders”. As part of this effort, Neal E. Miller and Barry D. Dworkin collaborated with Rockefeller University’s Instruments and Electronic Shops, and built a small, unobtrusive, portable device capable of measuring the spinal curvature of the wearer on a moment-to-moment basis, and of delivering training in daily-life settings through continuous, automated feedback. The basic principle was simple. When a poor postural position was detected, the patient was immediately notified by the device through built-in audio tones. Straightening the spine, until a predetermined criterion of correct response was reached terminated the tone signals. Such instantaneous feedback of information to the patients about the shape of their spine, it was hoped, would make them aware of their posture, and teach them, through “reinforcement”, to use their muscles to stand tall.
My talk will track the development of the “posture training device” and the art of partly automated therapeutic training it was meant to carry into daily life situations, from the design and construction of the first pilot model in the mid-1970s to the maturation of a commercial manufactured product in the late 1980s. First, I will place the invention of this particular device in the North American context of growing use of electro-mechanical modalities of investigation and intervention in the area of behavior modification, and then of the difficulties and challenges faced by its practitioners in the clinical application of biofeedback. The move in behavioral device technology toward automation, portability and provision of more or less continuous training at home, I will suggest, was partly about improving the questioned effectiveness of novel forms of behavioral treatment. Against this background, I will then describe the first steps taken by Neal E. Miller and Barry D. Dworkin to develop a corrective portable device for the treatment of scoliosis, including the incorporation of not only learning principles, conventions (i.e. criteria of acceptable posture), but also representations of adolescents’ ability to take responsibility for their treatment. I will focus my analysis on how the patients’ handling of the device and interpretation of its audio signals highlighted the difficulty of designing a perspicuous feedback system, leading to efforts to turn a corrective device into a “persuasive” one. Along with a series of changes in the material properties and operation principles of the posture training device, securing patients’ continued use of technology over time was then associated with a redefinition of the role of the therapist as a mediating agent, standing between the immediacy of unpleasant, potentially disrupting audio signals and the distant, uncertain prospect of improvement.