Embodying The Patient

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DOI: 10.1177/1357034X04042931
2004 10: 13 Body & Society
Marc Berg and Paul Harterink
Medical Practice
Embodying the Patient: Records and Bodies in Early 20th-century US
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Embodying the Patient: Records and
Bodies in Early 20th-century US
Medical Practice
MARC BERG AND PAUL HARTERINK
The modern medical body, Foucault has argued, is a four-dimensional exten-
sion in space and time. It is an anatomical space a collection of juxtaposed
organs interrelated, transformed and ultimately dissolved by the arrow of
(patho)physiology (Foucault, 1963). How is this body performed? In his study
of the emergence of this entity in the 19th century Foucault emphasizes that this
new structure profonde (1963: 89) of seeing and knowing is not a mere concep-
tual shift. He meticulously describes the dispositif,
1
the sociomaterial apparatus,
without which this new mode of knowing could not exist. Specically, Foucault
mentions the reorganizations in the medical profession and medical education,
and the transformation of the hospital into a site of study where patients can be
positioned and held in the focus of the gaze. Likewise, the emergence of a
range of investigative techniques the stethoscope, percussion and later chemical
tests such as urinalysis that probe the now only indirectly accessible inner
depths of the body is not a consequence of this epistemological change but a
constitutive element of it. Finally, the clinical gaze crucially depends on the exist-
ence of account books in which, for example, the frequency of signs was
Body & Society
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registered. Only by accumulating and tracing signs from groups of patients
would general knowledge about the pathological be possible.
Yet although this modern body might have crystallized in research practice,
in literatures and in educational practices, it would hardly be present in the day-
to-day events in turn-of-the-century medical practices. In this article, we want
to argue that the early years of the 20th century were an important episode in
the emergence of the patient incarnated with this particular body.
2
Specically,
we will focus on the coming of the patient-centered record in the United States.
3
In a necessarily all too schematic fashion, we will zoom in on closely interrelated
changes in the medical profession, in medical institutions, in the proliferation of
new investigative technologies and in the organization of the medical record. We
will argue that these changes were also intricately linked to the specic body the
patient acquired during this period.
Many historians have described this period as a crucial one in the history of
American medicine. It was during this time that the hospital obtained its pivotal
position within US health care. From a shelter for poor, sick inmates it was
transformed into a prestigious institution, where high-quality medical care was
delivered by professional care givers, based on scientic principles and techno-
logical innovations (Rosenberg, 1987; Stevens, 1989). Likewise, it was during this
period that the American Medical Association (AMA) managed to rmly estab-
lish its professional position. It instigated a reform of medical education, which
resulted in a decrease in the number of medical schools and the number of
licensed practitioners. This concentration of the educational system and the
concurrent establishment of standard requirements for medical schools led to a
consolidation of its professional authority (Starr, 1982).
The topic to be addressed here is the embodying of the patient: the produc-
tion of a patient with a body whose characteristics are the effect of the interrela-
tion of the patient with a growing number of professionals and investigative
probes, and with a medical record which becomes more and more signicant as
a gravitational node in these interrelations. Embodiment, here, denotes a process
rather than an a priori condition; it points at the achieved characteristic of having
a body. To embody is a verb that denotes the active incarnation of an entity
with a specic body; it is intended to draw attention to the activities of the
ensemble of entities the investigative technologies, the record, the patient, the
nurses which together perform this specic embodiment. It is a term intended
to dissolve the distinction between the body as a concept (as constructed in
scientic discourse for example) and the body as (subjectively) experienced.
None of these should be seen as ontologically or epistemologically prior to the
other in fact, the very distinction is itself a historical phenomenon. The very
14

Body and Society Vol. 10 Nos 2/3
Subject whose experience is at stake is itself part of the patient that we will see
emerging.
4
Embodiment, then, does not denote the state of having a material
body (as a prediscursive entity, or a phenomenological grounding point). It
does not point at a pre-existing unity. Rather, embodiment denotes the real-
time, ongoing process of delineating and substantiating this entity.
The medical record plays a special role in this story. This is partly an artifact
of our interest in this mundane yet surprisingly multi-layered technology. Yet
during the episode described here, the record becomes a crucial mediator in these
events. From being peripheral to the daily preoccupations of doctors on the
wards or with their private patients, it shifts gradually to center stage and
becomes a crucial hinge in the ongoing circulation of entities and activities. The
records new shape and functioning, we will argue, is fundamentally intertwined
with the new shape that both the patients body and the medical institutions
acquire.
The emergence of this body that we will trace should not be seen as an
implementation of ideas; it is not merely a lling in of the discursive space
outlined by Foucault that was somehow already present in potentia. Foucaults
body is too undetermined to merit such an interpretation, and the historical
events are too contingent. In the interrelation of the actors in this historical
drama, the actors will be seen to come to the stage already entangled in a plethora
of other, cross-cutting processes and interests, and the interrelations that we will
see emerge embody the patient in unexpected ways.
This article draws upon historical research about early 20th-century (and late
19th-century) medical practice, and upon contemporary medical and hospital
administration literature. This focus has its limits: it makes it difcult, for
instance, to elucidate the precise way patients participate in their embodiment,
and to investigate the agency of the body in these different congurations.
5
Yet
it does allow us to sketch at least the outlines of a series of events whose inter-
relations have so far received too little attention.
The Leather-bound Ledger and the Moral Body
An ordinary patient who had been admitted to one of the leading east coast US
hospitals in 1900 with a broken leg might have spent some six weeks there,
receive no X-ray (although the equipment would often be available), and have
his urine tested once (at admission). One or two entries might be found in the
record of the ward the patient was admitted to. At admission some medical
history, the nature of the fracture, the result of the urine test and the mode of
treatment might have been written down in a few sentences, and several pages
Embodying the Patient

15
later a remark might be found about the current state of the healing leg (Reiser,
1984; Howell, 1995). An attending physician would have checked him maybe a
few times more during his six-week stay, but such visits were sparse.
A well-to-do patient would have been treated in his own room, equipped with
a nice bed, wooden oors, better food and a private nurse. He might have
received even fewer tests, since he most certainly would not be bothered with
unnecessary interventions that were for teaching or research purposes. Yet he
would have seen his physician (and only this one) frequently (Rosenberg, 1987).
In the latter case, one might not nd any entries in the hospitals records at all:
the only notes, if any, might be found in the physicians own notebooks, which
he would keep in his own ofce.
Medical professionals were soloists. They had their own practices and
patients, and practitioners would care for these private patients throughout their
stay in the hospital. A personalized doctorpatient relationship was highly
valued and not just because this would ensure that paying patients would return
to ones practice. In-depth knowledge of the specic features of a patient (includ-
ing age, gender, class, ethnicity), and his/her region (including climate, density of
population) was still widely considered to be crucial to a properly attuned treat-
ment. Albeit this principle of specicity had been on the decline for at least a
quarter of a century, the notion that an individualized match had to be found
between medical therapy and the specic characteristics of a particular patient
and those of the social and physical environment was still an important maxim
in everyday medical work (Warner, 1986: 58).
There were very few paid positions on hospital staffs: doctors earned their
living through the fees from their private patients. Hospital positions were
attractive, nevertheless, since they gave doctors access to prestigious teaching and
research opportunities, which would heighten their professional status and
ensure a steady ow of paying patients. The clinical care for the poor patients on
the regular wards was a necessary chore that did not generate income but that
would albeit indirectly pay off (Rosenberg, 1987).
This situation is reected in the way records were kept. Wards, laboratories
and physicians all kept their own casebooks. In the Mayo Clinic, for example,
each laboratory, each attending physician and each (outpatient) surgeon kept
their own leather-bound ledgers.
6
These ledgers were a kind of log, in which
notes about patients and patient visits were written down, in chronological order.
In the Mayo Clinics outpatient ledgers, four or ve case histories were usually
entered on each page. In 1900, one such case history reads as follows:
16

Oct. 17 [name, address] . . . Early widow for 6 years. Menses reg somewhat increased for
past 6 months. Felt well until 3 months ago. Noticed an enlargement on left side. Once after
owing a good deal it seemed smaller 2 months ago.
Diag: a tumor the size of a childs head either from cyst or soft broid. (Quoted in Kurland
and Molgaard, 1981: 56)
It is hard to imagine this from our current point of view, but these casebooks
hardly played a role in the clinical care process. Doctors might keep their own
personal reminders in diaries or on slips of paper, but since they would often be
the only doctor seeing a private patient (and since not much would happen to a
patient on a poor patients ward), much could be done from memory. The case-
books, rather, were kept for administrative, teaching and research purposes
(Reiser, 1978; Kurland and Molgaard, 1981). The progress of medical science
was a more important reason for keeping records than the everyday care on
patients wards
7
and, we might add, this is also true of the X-rays and urine
tests that were performed on non-paying patients.
Records were mostly not even kept on the ward or at the site of care, but on
a specially designed stand in the physicians personal ofce for example (Craig,
1990). The records would often also be lled in after the case had been dealt with.
To trace a patients illness trajectory, one would have to nd all the entries that
were dispersed both within and between casebooks. Sometimes, indexes were
kept, through which individual cases and instances of a particular disease could
be found (Reiser, 1978; Kurland and Molgaard, 1981).
There is not much evidence of modern bodies, here. A broken leg is
mentioned, the patients urine might be analyzed once, and his/her discharge is
duly noted, with the addition cured or not. We do nd the utilization of
disease indexes to carve out epidemiological patterns, optimal treatments and
etiological reports. At this aggregate level of clinical research the interrogations
do address thoroughly modern bodies. General statements are made about this
novel universal. Discussing the Future of the Medical Profession, for example,
the President of Harvard University states in 1906:
The explorers and pioneers in medical science must be encouraged to press on their patient
work of analyzing all the processes which accompany disease, in order that they may learn
their actual sequences. Only through the knowledge of these sequences can real control over
disease be certainly gained. (Eliot, 1906: 348)
These statements hold true within the self-contained realm of the modern body
irrespective of the local conditions, geographic particularities or climatic varia-
tions that were so pivotal in earlier, 19th-century US medicine.
Yet in the delivery of medical care, patients seem to be rather ephemeral
beings, whose brief accounts eet through scattered pages of unconnected

17
records. Almost like the 18th-century German physician whose diaries Barbara
Duden has studied, doctors seem to record what passes them rather than to
attempt to xate these encounters in a universal framework (Duden, 1991). They
seem to narrate the time-space of their workdays and their patients accounts
rather than the four dimensions of Foucaults body.
8
Indeed, Rosenberg beautifully describes how the hospital still replicated in
microcosm the social realities that shaped the larger society outside its reassur-
ing red brick walls (1987: 309). Rather than bodies, patients were individuals
constituted by their social class and moral worth and it was this constitution
that medical treatment had to be tailored to. Poor patients were moral minors
to be disciplined, educated and used as learning material; alcoholics, the chroni-
cally ill and those with venereal disease were shunned and kept in almshouse
conditions proper to their moral inferiority. Rich patients, on the other hand,
belonged to the professions social stratum, and were treated with respect and
individual attention. The eas, crowded halls, discomfort, obligatory work duties
(for ambulatory patients) and patronizing behavior of the doctors and nurses
performed a form of embodiment more typical of turn-of-the-century lower-
class living than of anything related to medicine. The private nurse, personal-
ized attention, wooden oors and ne china likewise projected typical
upper-class embodiment into the private rooms of this medical institution
(Rosenberg, 1987: 309).
If anything, the records structure an unstructured casebook in which the
case descriptions were entered one after the other fed into this conguration of
the patient. Its pages were lled with short narratives: brief accounts of the
patient and what happened to him/her. The record, moreover, was only written
into in times of reection when the clinical work was done, and when the work
of the day had to be accounted for, or made relevant for future generations. It
still resembled more the writing of a diary than a formalized listing of cases.
The unconstrained narrative form, and the dispositif of the writing itself invited
a personalized touch, a lling in of the personae that populated the story: a
patient who is brave, worthy or disobedient; a tumor in a womans belly the
size of a childs head. This type of narrativization and contextualization of a
patients trajectory was a clear heritage of American 19th-century medicine, with
its emphasis on the need to place each individual case in the context of local
climatic conditions and the patients unique, social history (Warner, 1986). We
have argued that what lled these casebooks pages was not very relevant for the
patients embodiment in everyday clinical work. Also, we have argued that the
casebooks did feed into the emergence of modern bodies at the aggregate level of
clinical research. Yet, as far as their role in everyday clinical work goes, then, they
18

would have contributed to, rather than have undone the embodiment of the
patient as socially located moral agent.
Re-embodying the Patient: The Coming of the Patient-centered Record
Within a few decades this situation changed radically. The use of blood and urine
tests proliferated, and visualizing technologies such as X-rays and endoscopic
techniques became routine (Pasveer, 1992; Cartwright, 1995). Such technologies
had become part of medical training, and for the new generations of doctors they
embodied the newly emerged, truly scientic status of medicine. Concurrently,
the place of these tests shifted from a marginal addition to clinical work to the
sine qua non of medical diagnosis.
With these new technologies, the hospitals organization had also become
more complex: it now included, among other things, separate pathological,
photographic, X-ray, dietary departments and services, and one or more separate
laboratory facilities. In 1900, patients would seldom leave their room: in some
hospitals, even surgical interventions sometimes still took place on the common
wards. Now, however, both private and poor patients would be wheeled through
the hospital, from service to service. New medical specialties emerged radiolo-
gists, laboratory clinicians and separate billing procedures and bureaucratic
routines came into being to handle this increased complexity, and to turn the
hospital into a modern, professional institution (Craig, 19891990; Howell,
1995).
These changes went hand in hand with a thorough transformation of the
medical record. From a bound casebook in the physicians private ofce, with
handwritten notes gradually and consecutively lling the empty pages with
descriptions of the working day, the record became a patient-centered casele.
Each patient now had his/her own record, which usually consisted of a binder
or folder. In this folder, we would now nd the doctors and nurses progress
notes (still handwritten) and, in consecutive sections, correspondence with the
patient or about the patient, and standardized forms and graphs from the
different laboratories and other auxiliary services. The record would be empty at
the beginning, and slowly ll up with loose sheets, each new sheet being added
to their own section in chronological order.
This coming of the patient-centered record is often heralded as an important
move in the emergence of a medicine based on science: it thoroughly facilitated
scientic research, and it symbolized the fact that medicine was organized
around the patient rather than the individual doctor or ward (Reiser, 1984, 1991a,
1991b). Especially the former benet is stressed in the many articles that now

19
suddenly address the record in the medical literature. The importance of well-
registered clinical information is crucial for clinical research, authors argue:
In a way it marks the beginning of real clinical science, for each operation or each attempt at
any other form of curative treatment in any hospital is an experiment. It seems curious that
these experiments should not be recorded in most hospitals. Often the facts thus obtained
would be of the greatest scientic value. (Anonymous, 1914; cf. Slobe, 1923)
In comparison with case histories distributed through casebooks, the patient-
centered le offers a much easier and more efcient access to individual patient
histories.
The emergence of this new form of record keeping, however, was entangled
with many other considerations as well:
The value and need of an adequate system of case records for every modern hospital is so well
recognized and generally appreciated that it hardly seems necessary for me to dwell upon it
here. Apart from their importance in cases of tort, as a means of protection in suits for alleged
malpractice, and in all other medico-legal controversies, their paramount value is found in their
direct service to the community. This community service is brought about in two ways. First,
through the study of methods and results as shown in the records, the hospital is able to give
better and more efcient service, and, second, by giving convincing evidence of efciency and
an available measure of its service the hospital can seek and obtain more condence, respect,
and generous nancial support and thus extend its scope and increase its ability to serve.
(Stevens, 1919: 324)
The existence of adequate case records, this author argues, is a measure of the
hospitals service, and gives evidence of its efciency. This terminology reects
the importance of at least two interrelated developments which fed into the
emergence of the patient-centered record: the inuence of the scientic manage-
ment approach on hospital organization and the attempts of the American
College of Surgeons to reform surgical practice. (We will not further discuss a
third development that is clearly present in this quote: the emergence of the legal
status of the record as the true statement concerning the patients care and treat-
ment [Munger, 1928: 100].)
In the wake of the American Medical Association, rst of all, the American
College of Surgeons (ACS) had been attempting to enhance the homogeneity and
status of their profession. They wanted to set national criteria that would distin-
guish the Fellows of the College from the lazy and ill-trained surgeons of your
community (Clinical Congress of Surgeons, 1914: 72). One of their core criteria
was the presence of complete, accessible and accurate records for all patients,
which had to be kept by the hospital rather than by the individual physician.
9
Only through the existence of such records would scientically based care be
possible, according to the College. For the College, however, there were at least
two other motives at play. First of all, by focusing on the operation of hospitals
20

rather than the activities of surgeons, they attempted to increase their inuence
on hospital management (Atwater, 1989; Long and Golden, 1989; Stevens, 1989).
By focusing on the doctors setting rather than on the doctors own performance,
they set criteria for quality which effectively enhanced their sphere of inuence
in hospitals without impinging on the individual doctors clinical autonomy. In
addition, proper records were also the only way to weed out the ill-trained
surgeons from the worthy ones. The opportunity for professional self-control
was thus an important early motive for the introduction of case records (Reverby,
1981; Reiser, 1984):
The advantage of having a complete hospital record such as Dr. Bottomley speaks of, not a
long one, but a complete one, was illustrated to me . . . [The superintendent of a large municipal
hospital had received a complaint that the performance of one of his physicians, Dr. So-and-
So, was not satisfactory.] The physician in question was told of the affair . . . and became very
angry and said that he was being persecuted; that his results were just as good as anybody elses.
Meanwhile the superintendent . . . had asked [his] clerk to take the records of four men
occupying similar positions on the staff, the man in dispute being one of them, and bring him
these mens records of operations for three months, the character of the operation, the result,
and the number of days the patient remained in the hospital, so that when this man came to
him and said he was being persecuted he had denite facts to show that his death rate was high,
and that the average length of stay of his patients in the hospital was longer than any other
mans. (Dr Homer Gage, discussant in Bottomley, 1918: 2212)
Yet the ACSs focus on adequate record keeping did not in itself pave the way
towards a patient-centered record system. In fact, their rst criteria speak about
proper record keeping in general they do not delineate the patient-centered le
as the preferred way of record keeping. As long as records are complete and
contain a certain set of standard data, they fulll the ACS criteria. The step
towards the patient-centered record was entangled with the spread of the prin-
ciples of scientic management within hospitals, which did not so much come
from the medical profession as from hospital ofcials and the newly emerging
profession of medical record librarians. Parallels were made with similar
developments in hospital administration:
With the adoption of more uniform and systematic methods of accounting in the adminis-
tration of the hospitals throughout the country . . . the same line of improvement might be
continued in the matter of hospital clinical records. (Brotherhood, 1913: 1205)
The patient-centered record, rst developed at the Mayo Clinic, was modeled
after industrial examples:
For more than a year [this physician] studied the problem, went travelling to see what others
were doing, and, getting no help from medical men, turned to business and industry for ideas.
The dossier system he subsequently evolved became a model for medical records. (Clapesettle,
1954: 320)

21
Scientic management stood for a scientic approach to the production
process, in which complex tasks were split into standardized and meticulously
circumscribed subtasks to enhance the efciency and controllability of the
overall process (Yates, 1989). A precise, centralized system of administration is a
prerequisite for such an approach. In a 1941 textbook on medical record keeping,
this view is nicely summed up:
The basis of this standardized service is to know what the hospital is doing, and to record its
work in such a way as to enable an appraisement to be made of it. . . . Records, therefore, are
a prime essential in any program of hospital standardization. . . . Case records are the visible
evidence of what the hospital is accomplishing. . . . Not to maintain case records properly is
like running a factory without a record of the product. (Huffman, 1972, 6th edn: 21, quoting
an editorial in the 1919 issue of Hospital Management)
Throughout ofces in the US, loose les were replacing bound books. Files of
documents arranged by subject or by name became the generally preferred way
to permit administrative documents to accumulate (Craig, 19891990). Just as
letter books with chronologically stored in- and outgoing mail were replaced by
vertically stored, loose les arranged by subject, and just as employees and
nursing pupils each acquired their own records, so the casebook was replaced by
the patient record (Craig, 19891990; Yates, 1989).
Meanwhile, the medical professions rst emphasis on proper record keeping
had slipped from their hands: the improvement of medical record systems took
on a different shape than they had intended. The medical record librarians now
established themselves as the guardians of proper record keeping. They aimed at
ensuring a system that was optimally congured to the needs of a modern
hospital whether or not this corresponded to physicians needs. Doctors
complained about the proliferation of preformatted forms, in which they only
had to ll in a few words or even just select a term from a pre-given list. Such
forms, they noted, shifted responsibility for the content of clinical work from the
individual doctor to the system which developed and checked up on the forms
(Howell, 1995). And indeed, statisticians and record ofcials started to publicly
scold physicians for their poor record-keeping practices. Doctors fears of stan-
dardization were ridiculed:
One realizes perfectly that any suggestion in the direction of standardizing case history
writing, by the process of putting into operation methods which have been found sound and
useful in other branches of science and in modern business, will at once be scornfully or even
derisively received by some. It will be argued that any such process tends to cramp their indi-
viduality. This argument is perfectly valid. It will inordinately cramp such portions of their
individuality as nds its expression in carelessness, inaccuracy, forgetfulness, and inattentive
observation. (Pearl, 1921: 1878)
22

Medical record ofcials dened themselves as the watchdog of the hospital
records (Brough, 1935) and sometimes started to directly supervise doctors
work:
The record room clerk shall post each day on a bulletin board at the entrance of the hospital
the number of incompetent histories opposite the name of the member of the staff responsible
for their completion. (Auchincloss, 1926: 308)
The specic form that the patient-centered record took, then, has to be seen
as the contingent merging of professional reform initiatives and the extension of
principles of scientic management into the organization of hospitals. Through
this interplay of drives, the patient replaced the ward or the individual physician
as the unit of the record. Rather than signifying a humanistic desire to place
the patient at the center, it received an initial impetus as an attempt to enhance
professional control over hospitals and over individual doctors. At the same time,
it was both a response to and a prerequisite for the increase in the number of
patients that hospitals treated, the increase of patient information being gener-
ated and the increase in organizational complexity (Howell, 1995). The move
from a bound casebook oriented towards research, administration and teaching
to a case le primarily oriented towards patient care reected a need to
coordinate a growing number of people and events. The case records dened and
distinguished the organizational subsections of the hospital, and allowed their
mutual collaboration: all notes concerning individual patient trajectories were
automatically led as they were created, in the single binder that stood for a
single patient (Craig, 19891990, 1990). The patient-centered record was to
medical work what the introduction of cost accounting was to hospital adminis-
tration. It afforded the overview and management of increasingly complexly
structured units (the hospital and the patient), and it represented the science
that both physicians and administrators so craved to be identied with.
Just as the bureaucratic organization of the hospital could only develop
through the existence of this simple artifact, and just as the record played an
important role in the reshaping of the medical profession, so the patient-centered
record became a crucial actor in the performance of a new mode of embodiment
(Berg and Bowker, 1997). The increasing number of probes produced inscrip-
tions that accumulated in the sections of this record; the record dened and
separated these outputs and unied them in a single folder or binder. Partly
mirroring the compartmentalization of the hospital organization, a compart-
mentalized yet unied body emerged here, in which organs or organ functions
are each allotted a separate section in the le, or a separate portion of a prefor-
matted form. In the interrelation of proliferating techniques, patient-centered

23
record, doctors, nurses and the patient, a body emerged whose dimensions do
not map the everyday sites and events on the ward or in the clinic. This body
extends in an anatomical/pathophysiological space and time which is traveled by
blood cells and growing tumors, and which is explored through urinalysis and
endoscopies.
The historian Barbara Craig describes the switch from casebook to case le
as permitting the natural accumulation of documents (1990) ling them at the
moment of creation, in sections, that are organized chronologically. Yet this
sheer naturalness of the patient-centered records functioning, this seemingly
perfect match to the nature of medical work has to be seen as an effect to
which this record contributed. That is to say: the new space-time that emerged
between the covers of the record was a novel phenomenon. The embodiment of
patients was loosened from the workings of the day-to-day life networks that
permeated the hospital walls; the space-times that doctors now traveled in were
less and less measured by moral worth and social standing. Rather, studying the
X-rays and other forms, doctors could enter the space of a tumor that grows, or
a fracture that heals: where does it reach, what structures does it leave unaffected,
what type of fracture are we dealing with? Similarly, patients encountered
different specialists, each focused on their own domain, and each carving out,
with their probes, questions and interventions, a separate instantiation of this
novel body.
This analysis should not be understood as saying that this modern body was
a unitary phenomenon. Foucaults discursive potentiality was not slowly lled
with nicely complementary organs and processes. The dimensions that emerged
through these interrelations did not (and do not) neatly map out an anatomical
atlas, or a (patho)physiological handbook. The section urinalysis yields signs
that may tell some isolated details about the kidneys and/or the bladder: it may
inform as to whether the bladder or the kidney is infected, or whether one of
these organs is bleeding, but it might not inform about cancerous growths in the
kidney, for example, or say much about why there is blood in the urine. Likewise,
urinalysis is not just about the kidney and the bladder: it may also indicate some
general physiological disorders such as diabetes. Similarly, while X-rays carve
out anatomical structures, they cross-cut different organ sections (heart and
lungs in a thorax X-ray, for example) while only showing a few of the anatomi-
cal parameters a doctor might have been interested in. These probes and sections,
then, do not together produce a complete, comprehensive map of the patient.
They are rather an assembly of diverse, scattered collections of traces that
delineate partial instances of the modern body. Leang through the record, the
physician encounters an array of relatively self-contained logics, whose linkage
24

is a task in itself: X-rays showing a growing tumor, progress notes showing
unchanging complaints, urinalyses showing a decreasing general condition (Mol,
1998, 2003).
We want to focus in somewhat more depth on two ways in which we can see
the patients body being reshaped. In both instances, the record plays a central
role and in both instances, this role should not be seen as secondary to some
intellectual development, but as affording this development in the rst place.
Re-historizing the Body
In the second half of the 19th century, a break with the anatomic, static tradition
of seeking truth in anatomical traces occurred (Cartwright, 1995: xiii). Gradu-
ally, a thoroughly temporal and quantitative mode of conceptualizing the body
replaced medicines strictly anatomical, qualitative focus. Reshufing the hier-
archy of dimensions within Foucaults modern body, physiology was focused on
bodily processes, not structure. It emphasized temporally organized events rather
than spatially organized composition. It did not do away with anatomy: the
processes, after all, unfolded within these spaces. Yet this temporal reality, this
fourth dimension that animated the three dimensions opened up by the
anatomists instruments, more and more became the nal arbiter. Whereas the
anatomical trace was once the nal touchstone of medical knowing, it was now
seen as a mere derivation of the essential, physiological processes that constituted
health and disease.
Again, this mode of knowing could only emerge with a novel reading and
writing technology: the graph. Where a pictorial form of representation such
as a photograph, or an atlas generates static, anatomic congurations, this non-
pictorial form of representation centralizes time (Cartwright, 1995: 5). A graph
emphasized motion, change, development. It was life redened as process
inscribing itself on paper; the physiologist attempted to make phenomena trace
themselves (Braun, 1992: 22, 83; cf. Daston and Galison, 1992). As one of the
founders of the graphical method in physiology phrased it, the curves on the
at surface make time differences reappear as spatial differences (Helmholtz,
quoted in Holmes and Olesko, 1995: 203). A graph transformed the subjective,
eeting experience of a physical event into an objective, visual, graphic represen-
tation that was a permanent record of the transient event, a record that could be
studied and criticized by a single physician or by a group (Braun, 1992: 18).
Graphs are inscriptions that transform events occurring in the space-time of a
hospital ward or laboratory into repetitive phenomena, occurring in and linking
across a linear time that is lifted out of the wards time zones. They establish a
historical continuity in a double sense. The graphs grid, rst, extends reassuringly

25
into both the past and the future: the grids basic structure is unbounded and
completely regular. A pulse transformed into points mapped out on this grid
acquires these same characteristics. The actual pulse measured in an experiment
becomes just the contingent, local realization of a phenomenon that stretches out,
virtually, linearly and regularly, beyond the connes of the experiment. Its bounds
are only the boundaries of life itself. In addition, a historical continuity is
produced because the graph is accessible at any moment. The specic tracing can
be re-scrutinized at any later time; it can be compared to other processes, of other
physiological entities, or of the same individual later in time.
In medical practice, the patient had been historized through the narrative
recounting of his/her life, of important medical events, and of the social and
physical environments that structured both. The patients individuality had been
based on this unique history; it had acquired its specicity through the specic
constellation of class, climate, geography, and life events that constituted that
patient. Graphs depicting uctuations in temperature, pulse and/or respiratory
rate data can already be found in clinical records in the last quarter of the 19th
century. These graphs were usually drawn by hand, and pasted into the bound
casebooks, next to or over the doctors entry (Reiser, 1984; Warner, 1986). Yet
these graphs were isolated occurrences, spanning short periods, and when the
wards thermometer broke the graphs would simply stop (Warner, 1986: 155). In
1909, an anonymous commentator in the Journal of the American Medical
Association praises the power of graphs and tables, reports their increased use for
purposes of research yet laments their limited use in medical practice. The
graphic method of recording temperature, pulse and respiration and tabulating
the ndings of variable features such as the weight, conditions of the blood or of
the gastric or renal functioning as discovered in the lab, the blood pressure, etc.,
he argues, are highly valuable:
[These methods] project the changing features of disease, acute or chronic, in such a manner
that the mind necessarily conceives a broader picture of the condition. . . . [Yet] in the days
work of the ordinary clinician, in the study of the cases which are never to be reported, how
seldom is this efcient aid to diagnosis, to prognosis, to treatment, utilized! The habit of
appending to every case record a table of the variations of at least some of the important
factors, which may be glanced over and grasped in an instant, will be found to do much toward
correcting that mental myopia to which all are in some degree subject. (Anonymous, 1909)
In the everyday practice of medicine, the emergence of the modern body at
rst implied a predominant focus on the lesion, on anatomy as the site of disease
and interest, which would last well into the 20th century (Kurland and
Molgaard, 1981; Armstrong, 1985; Lawrence, 1985). A thoroughly temporal
focus, historizing the patients body in a new, unilinear and universalizing way
only emerged after the appearance of the patient-centered record. In the
26

everyday practice of medicine, we conjecture, this latter technology materialized
in a more general way the logic of the graph. The patient-centered record would
generally contain several graphs (pulse, temperature), and it would contain
temporally organized tables for quantiable urinalysis results, blood test results
and so forth. Yet maybe even more important, its very functioning re-historized
the patient. Its sections were all organized chronologically, so that leang
through the record would become a journey through time. More precisely, it
would become a journey through physiological time. The repetition of pages,
the sequences of tests and the grids of the graphs transport the reader into the
time zones of the rise and fall of temperature peaks, the increase and decline
of blood cell levels, or the steady or irregular growth of a tumor (Berg and
Bowker, 1997).
Compared to the series of disjointed, brief narratives in a casebook, the
patient-centered record affords a physiological historization of the body in
myriad ways. Its thickness is already a measure of time thick les emphasizing
chronicity and its standardized, preformatted and serially stored forms struc-
ture and unify time much as the graphs grid does. In the further history of
medical practice, this historicity has generalized beyond the emphasis on physi-
ology and this generalization is only thinkable from a practice that has already
incorporated the patient-centered record as a core, gravitational node. Illness,
David Armstrong argues about 20th-century UK general practice, became less
the momentary revelation of the clinical examination and more the process of
becoming ill, or reacting to illness and to treatment, and to becoming well (1985:
662). Early in the 20th century, authors already argued that a patients treatment
was not complete without follow-up. Checking and registering the outcome of
ones therapeutic activities was a sine qua non for the development of clinical
science (Howard, 1915; Reverby, 1981; Reiser, 1984):
The value of a suitable follow-up [record] system needs no explanation. There is no room for
argument. It is the only adequate way of checking up results, of recognizing and correcting
mistakes, of discovering the causes of failures and of nding means of preventing their repeti-
tion. Furthermore, it helps to convince the patient of the sincere interest on the part of the
physician in his welfare and thus foster their cooperation and mutual understanding. (Stevens,
1919: 325)
This emphasis on follow-up was followed later by an extension into the
other temporal direction of the linear time grid: early diagnosis and intervention.
When both life and illness are seen as a temporal continuity, intervening early to
prevent later disease became a logical possibility. [Pushing] the identication of
illness or its precursors back in time was part and parcel of a logic of medical
intervention that had shifted from the lesion to a temporal space of possibility
(Armstrong, 1985: 663; cf. de Vries et al., 1997). This temporal space was not

27
some ephemeral discursive notion or idea: it was performed at least in part in
the very structure and functioning of the patient-centered record.
Processing the body in medical practice, now had also become embodying the
patient-as-process. The medical record was of course merely one node in this
changing dispositif. The patient-centered record performs a historized body; it
invests the patients body with a linear, accessible and continuous history. Yet the
coming of this record was tied to other developments that in themselves
contributed to the emergence of a temporalized body. Recurrent tests now
subjected patients to daily routines: patients were awakened early, or even at
night, to have their temperature taken (Rosenberg, 1987). Infusions and measure-
ments were meticulously timed and repeated at xed intervals, and later measure-
ments were compared to earlier ones in order to note signs of improvement or
physiological process-failure. Likewise, therapies began to perform the body-as-
process. Rather than restoring a lesion, insulin therapy compensates for the
bodys failed sugar regulation mechanism; rather than being a single-moment
intervention on a spatial disorder, it performs a chronic patient who monitors the
physiological processes that are her body and that simultaneously threaten to
decompose it. Finally, the temporal inversion that took place between the
moment of intervention and the onset of symptomatic disease derived from the
notions of early diagnosis and prevention is unthinkable without a record in
which these long time stretches are brought together and made overseeable. At
the same time, in a practice in which early diagnosis, prevention and follow-up
have become a central logic, the patient is embodied with a fragile body, ruled by
processes that are continuously in need of monitoring, regulation and control
(Armstrong, 1983; Cartwright, 1995).
Subjectifying the Body
How do you differ from information about you? Are the facts that describe your individual
characteristics distinct from you and those characteristics? . . . Is the information that your
blood type is A, that you were treated for pneumonia at the age of 13, and that you are
currently under the care of an ear, nose, and throat specialist for upper respiratory infection
and severe allergies, separate and distinct from you your mind and body in other words,
separate from yourself? It is difcult . . . to distinguish the patient from the information
necessary to the care and treatment of that patient. . . . From our point of view, it is imposs-
ible to separate the patient from the patients medical record. There is, of course, the obvious
physical separateness of the two, but this is of small importance when one considers the over-
whelming signicance of the unity of the patient and the recorded information that describes
exclusively the health care of that patient. (Waters and Murphy, 1979: 10)
From our point of view, this basic handbook for students in the medical record
profession states in 1979, it is impossible to separate the patient from the
28

patients medical record. Clearly, something more has happened to the patient
and his/her record than we have discussed so far. This is a traditional text, written
for students in a eld that, at rst sight, might not seem to be a site of
postmodern innovation. How can these authors, then, treat the obvious physical
separateness of record and patient so lightly? We would conjecture that they are
able to do so because the modern medical record is one of the pivotal elements
that perform the person/patient-as-Subject. In other words, the information in
the record is you your mind and body since this specic embodiment has
emerged together with the modern medical record.
The introduction of patient-centered record keeping, we argued earlier, was a
core part of the redenition of medicine as a complexly organized, collective
enterprise, which could be run and managed according to scientic principles.
Yet where the practice of medicine became collective, the patient became a
modern individual. The patient-centered record might be seen to perform the
patient as a Subject: a bounded, coherent and unied self, with a history that
forms a whole, and an inner core that is unique to this person and constitutive
of who she or he is. As one important development amidst others ranging from
the way hospital rooms were redesigned to changing practices in political
representation the medical record contributed to the production of the liberal
humanist self; a Self, moreover, which has a body from which it is distinct yet
inseparable, much like a patient has a record.
These are all conjectures these claims clearly surpass what we could hope to
demonstrate with the data and within the scope of this article. Yet however
conjectural, these claims are not mere rhetoric. The patient record concretely
attires the patient with many of the characteristics of liberal subjectivity (Hayles,
1999): coherence, boundedness, centeredness, unique historicity, self-determi-
nation. First of all, the subject of health care is that which is represented by a
doubly continuous history (see above), which unfolds from cover to cover, from
birth to death. The practice of medicine is a continuous looping movement,
coming back to the record time after time, adding new layers of history, and thus
performing the patient as an entity conditioned by a coherent past and circum-
scribed by the spatial and temporal limits that match the boundaries of the
record.
Likewise, the patient-centered record centralized the patient in the organiz-
ation of medical care rather than the physician or the ward. Whereas in the
casebooks separate indexes were necessary to trace individual patients trajec-
tories, patient-centered records were self-referential: they indexed themselves
(Craig, 1990). That which bound them the subject of the record was the name
and/or the birthday of the patient. Bounded and ordered by the unique markers

29
of selfhood, in other words, the hospital archives were slowly lled with
individualized, anatomically and pathophysiologically structured histories.
Individuality was no longer a phenomenon of being determined by external,
local conditions by social class, climate, family conditions, occupation and so
forth and of narratively structured accounts in bound casebooks. The inter-
spersed accounts, whose open-ended structure seemed to follow the specicity
of a given situation, we conjecture, reected the open-ended, contextually deter-
mined individuality of turn-of-the-century patients. This outwardly directed
individuality, which is constituted by exterior, contingent circumstances, is
replaced by a fundamentally inwardly directed individuality. Individuality,
now, presupposes an inner core, an inner space operating according to an inner
logic, a certain autonomy and self-determination just as the record, now, self-
indexes and self-les, is highly structured and is closed in upon itself.
The emergence of this conguration, moreover, was directly linked to several
of the other processes that constituted the liberal Self in the early decades of the
20th century. The central record room, where the medical records were now to
be stored, was a node in a much larger spanning web:
Calls for assistance come to the record room from many quarters, and a helping hand is
willingly given. To mention a few of the allied organizations from which many of these
requests come, there are other hospitals, medical schools, pension bureaus, insurance
companies, the industrial accident boards, workmens compensation organizations and, by no
means least, the department of public health. (Whiting Myers, 1932)
All these institutions kept records, exchanged information, and produced persons
as individuals with personal rights, personal histories of risks and disability, who
were equal for the law and for the bureaucracies that counted, classied and regu-
lated them (Bowker and Star, 1999).
The medical record, for example, became a document that could testify for the
patients self-determination in the courtroom as well:
In a will contest, the plaintiff complained that she was the common law wife of the decedent.
Over her objection, the trial court admitted in evidence certain charts and records of a hospital
in which he had been a patient, in which he was described as a single man. This information
was based on statements made by the decedent to hospital attendants. (Anonymous, 1933)
Interestingly, in this case the Supreme Court later held that these charts and
records were hearsay, self-serving and inadmissible. This Court stated, however,
that there may be cases in which the circumstances are such as to make state-
ments so recorded admissible as a part of the res gestae (Anonymous, 1933). The
de-individualization of record-keeping practices, the institutionalization of
procedures that made the records independent from the individual nurse or
doctor who happened to record an item, was what turned the record into an
30

objective representation of events which then could, through this very fact, be
read as a true record of this individuals wish (Smith, 1990). Through the
stabilization and anonymization of record-keeping practices, the subject of the
record became endowed with an established past, who had desire A at time x and
did B at time y.
Finally, the emergence of the patient-centered record system was contested
and debated by contemporaries because of the way it performed patients as
liberal selves. In the early decades of the 20th century, records of private patients
if they were made at all were kept and owned by their private physicians.
This ownership symbolized the already mentioned unique relationship between
doctor and patient, and the importance of trust and condentiality. Private infor-
mation was something that should remain between the doctor and his patient.
Notes on poor patients, on the other hand, might be scarce, but if they had been
made they would be more readily retrievable: they would be found in the
assistant physicians casebooks, for example.
The American College of Surgeons had stated that record keeping should be
the hospitals responsibility (Clinical Congress of Surgeons, 1914; Reiser, 1984).
This signied a breach in condentiality that many physicians found unaccept-
able for their private patients. Dr Mayo, in whose clinic the patient-centered
record was rst introduced, commented ironically on such objections that he saw
as resistance to centralized record keeping:
We hear objection sometimes to complete records for private patients . . . the poor have had
records because, let us say, they could not help it; the rich and the middle class are just as
deserving as the poor and they havent the records. (Mayo, 1919, cited in Reiser, 1984: 311)
In 1922, however, a public health committee laments that private records are still
often simply absent in the hospitals central record room:
The private patient records are worse than the ward records. In some of the hospitals, no
records of the private patients are required for the central le, thus making the relationship of
the patient to the hospital purely that of a hotel. (Lewinski-Corwin, 1922)
In an investigation of 66 hospitals in 1935, 80 percent of the hospitals reported
that they handled private and ward records in the same manner. Yet even at that
time the resistance against this erasure of difference can be read from the statis-
tics:
In 8 hospitals (15.6 per cent) private patients records are kept in the central record room and
handled as ward records, with the following differences. . . . Private records are stamped
private and are never used for study in 1 hospital. They are used only when permitted by the
attending doctor in 3 hospitals. The blood Wassermann report is not placed on private records
in 1 hospital. A few records of psychiatric cases are not placed in the central record le in 1
hospital. Records of courtesy staff patients are not included in the central record room in 1

31
hospital. A separate le is maintained for private patients records in 2 hospitals (4 percent).
(Stokes et al., 1933)
The creation of the patient-centered record, then, implied an individualization
of the poor and the increased valuation of their status as patients through the
granting of individual records to them. To prevent nonlegitimate inquiries from
insurance companies and from others which attempt to use the hospital to pull
its chestnuts out of the re, both private and ward patients are now asked for
permission for the giving out of information (Anonymous, 1930). This increased
valuation of the poor at the same time implied a democratization of private
patients, whose medical information would now be stored in the same les as
one comparable body among many.
The standardized forms and modes of data collection that typify modern
record-keeping practices have often been criticized as contributing to the
dehumanization tendencies that would plague medicine (Reiser, 1978; Howell,
1995). If anything, however, the modern medical record is part and parcel of the
dispositif that performs the very normative ideal that is seen to be threatened: the
whole self. If we describe the emergence of the modern body in medical prac-
tices as signifying a shift from a focus on the whole person to a focus on isolated
body parts in which personhood is eradicated (cf. Jewson, 1976), we overlook
how these very same processes helped constitute modern personhood in the rst
place. Here again, however, this should not be misread as suggesting any singular,
unitary instantiation of a subjectied body. There are at least two ways in which
the medical record can be seen to help perform diversely subjectied bodies,
whose internal coherence is a matter of constant, and only partial, achievement.
First of all, as we mentioned earlier, the patient-centered record performs a
patient who is thoroughly fragmented: the individual sections may all project
similar time grids, but the links between these patterned traces are not in any way
facilitated or afforded by the record. In fact, current critics of the medical
records set-up (which is still basically the same as in the 1920s) chastise the
record for this failure.
10
In his critical history, Stanley Reiser calls the persisting
record a dinosaur:
. . . the record remained a pastiche of laboratory reports, X-ray reports, nurses notes, social
workers notes, statements by patients, objective facts, and subjective narratives. [It was] the
endpoint of the network of communications that bound together the specialties dividing
medicine . . . [and a] fragmented almanac of [the patients] total medical experiences. (Reiser,
1978: 20910)
The medical record is not only internally fragmented. There is also not one,
single record of each patient: there might be dozens, one in each (para-)medical
facility the patient ever visited. Even within one hospital, there are often several
32

records of one patient: one for each outpatient specialty, one for inpatients, and
so forth. Sometimes, psychiatric notes are kept separately; sometimes, the
pediatric department does not integrate its records with those of other special-
ties. At this level as well, then, fragmentation is rife; the subject of the records
only adds up to a singular, circumscribed subject through much integrative work.
A single record for the whole patient has been an ideal since the beginning of
the 20th century, but only a few hospitals even managed to just have one record
for each patient. Performing circumscribed subjects, it appears, is a costly affair.
The infrastructure necessary to have such a so-called unit record is immense,
the logistics and standardization required appeared to be unrealizable, and the
costs are prohibitive for most institutions (cf. Stokes et al., 1933; Genevieve
Morse, 1934).
In addition to this fragmentation of the patient, the patient-centered record
can also perform different patients. The following historical examples are necess-
arily brief and somewhat extreme, but they illustrate the different ways a Subject
can be performed by particular dispositifs (Cussins, 1998; Gomart, 2004, this
volume; Mol and Law, 2004, this volume). The rst example describes a British
Army patient record, developed during the First World War and described in the
Journal of the American Medical Association. This patient record solved the
problem of fragmentation: it is one of the very few examples of a truly unitary
patient record. It would seem, however, that achieving some humanist ideals of
liberal subjectivity implies losing others. Unity, here, is achieved at the cost of
limited self-determination and increased objectication:
The sick or the wounded soldier passes through many hands from the time he is struck down
on the eld till he reaches the hospital in England. It is important not only for his treatment
but also for the compilation of the medical history of the war that complete records should be
kept. The case sheets that have been used in the army, however suitable in time of peace, have
been found cumbersome under the pressure of this gigantic war. The statistical department of
the Medical Research Committee . . . has devised a new medical eld card to serve as a
condensed diary of the patients hospital career at the seat of war. The rst entry is made by
the eld ambulance; it gives the date of the wound or onset of illness, a note of the adminis-
tration of the antitetanic serum or morphine, and the diagnosis. The card is enclosed in a stout
envelope, which is tied to the mans tunic, and goes with him to the casualty clearing
station. . . . The envelope contains spaces for particulars of the ambulance train, convoy and
hospital ship by which the man is transferred, as well as for information regarding his needs in
transit. . . . Thus the patient reaches the home hospital with a brief record of the early stages
of his case. [There, index cards are added.] . . . The cards eventually reach the Medical
Research Committee, which arranges and les them for future reference. (Anonymous, 1918)
A truly holistic performance of the patient, then, and a form of integrated care
avant la lettre required an infrastructure as tighly coordinated as the military, and
a patient as standardized and anonymous as a wounded soldier. Only in such a

33
case would it have been possible to have this foolproof mode of record trans-
portation, and to have a small and preformatted card covering all possible needs.
A similar trade-off occurs in the following example. Here, a New York
dispensary also wants to ensure continuity of care, and also comes up with a
record that can be carried around:
In Bellevue we frequently encounter patients who show scars of previous operations, who give
histories of denite illnesses or injuries, who tell of having had blood examinations or injec-
tions made. On inquiry it is often found that the patient is totally ignorant of what the
operation was for or what was found, of what the illness was, or what the blood test showed.
In the study of dispensaries made some years ago, there was shown a very small book, slipping
easily into a vest pocket, which each patient in one of the dispensaries was given. This book,
which was carried or kept by the patient, contained very brief statements, over a physicians
signature, concerning the complaints from which the patient suffered. . . . If this system
became general, it would result in time in a large number of patients having an accurate record
of their past medical history. (Wallace, 1922)
Here, patients carry their own history around because they are too ignorant to
be trusted themselves as an informant about their own medical history. The
physicians signature ensures the validity of the recorded information, and the
small size of the book ensures that the patient can always carry it with them.
Again, unity and boundedness are achieved through performing the patient as
incompetent and unt to speak on his or her own behalf to exert his or her
selfhood. The little pocketbook and the doctors signature ensured the accuracy,
continuity and self-knowledge that the patient could not provide. Of course, in
this case the patient can challenge this dispositif by losing the booklet, or by
refusing to hand it over to a doctor. Yet, in this set-up, such behavior could only
be interpreted as a negative sign, as a conrmation of the fundamental untrust-
worthiness of the patient, who cannot even take responsibility for storing and
carrying with him or her such a simple book.
In the nal example, we encounter an interestingly different mode of perform-
ing the patient. This is a record system discussed by the Ohio State Department
of Health. Here again, the emphasis is on providing continuity. Yet in this case,
continuity seems to be achieved through performing the patient as a competent
agent, capable of recognizing and acting in pursuit of his or her own interest.
Attempting to ensure a patients access in all public (venereal) clinics throughout
the state, a so-called transient record is presented:
On the rst page is printed the following: This record is intended for the use of persons whose
business or profession does not permit them to complete a course of treatment with any single
physician or clinic. Presentation of this card at the ofce of any city department of health will
entitle the bearer to be directed to a reputable physician or public clinic. (Thomson, 1920)
The record is maintained by the patient, who is stimulated to ensure proper use:
34

Always be sure that the physician or clinic chief makes a proper entry of your treatment. This
entry comprises the date, amount of drug used, and signature of the physician. (Thomson,
1920)
Such a record, the author argues, enhances the involvement of both patient and
doctor:
On the fourth page are printed instructions for patients with gonorrhea and syphilis. . . . Such
a record is of great value, as it will enable doctors to give patients more intelligent and careful
treatment, and interests patients in their condition; thus resulting in better and closer cooper-
ation between physician and patient. (Thomson, 1920)
A record that speaks of cooperation between doctor and patient and a patient
who is urged to check the physician: this is a mode of performing a patient that
is radically different from the other examples. Only a few decades earlier,
venereal disease patients would have been considered moral inferiors, unworthy
of any self-determination let alone of a conguration in which they would be
put on a par with a physician.
We may be reading too much into these brief excerpts: the latter case, for
example, could be seen as just a more subtle way of extending the control of the
State Health Department over a group of patients that is hard to monitor. Yet
these examples do indicate how record systems could be part and parcel of
dispositifs that perform the patient in thoroughly different ways. In the
conclusion we will briey touch upon a more recent development that might
fulll a similar role the electronic patient record.
Conclusion
Embodiment should be seen as the process of incarnating a person with a body,
the specic characteristics of which are open to historical and/or sociological
investigation. Whereas several other articles in this volume focus on the perform-
ance of bodies in current medical and biological practices, we have taken a more
historical approach. We have attempted to link changes in medical record-
keeping practices that took place in the rst decades of the 20th century to
parallel changes in the way patients are embodied within medical practices.
In doing so, we have undoubtedly overstressed the role of this artifact, the
medical record, in the story. Yet the power of such seemingly innocuous yet
ubiquitous administrative technologies is easy to underestimate. It is easy to see
the sheer mundaneness and matter-of-factness of the working of record systems
in medical practices as proof of their natural t to the way medicine works.
Rather, we have argued, the patient-centered record actively feeds into the
production of the bodies that populate medicine. We have argued that the

35
emergence of a physiological body, of the temporal axis as the predominant axis
of medical diagnosis and intervention, would have been unthinkable without the
presence of this simple apparatus. With regard to the constitution of the liberal
subject, it is clear that the role of the medical record as such cannot be extensive.
Yet it is one element amidst a whole battery of similarly functioning records in
administrative ofces, insurance companies, police departments, government
bodies and so forth that became ubiquitous around the same time. As such, its
modest performative role can be seen to be mirrored and amplied by many
other similar devices.
At the end of the 20th century, some commentators argue, we are witnessing
a transformation in medical record keeping that is as radical as the one described
in this article (Ornstein et al., 1992). From paper-based, coherently bound and
centrally archived individual records we will gradually move towards electronic
forms of record keeping. Through digital processing, data dispersed over many
different sites may be combined into virtual patient records, specically tailored
to the health care professionals needs, affording unprecedented potential for the
coordination and accumulation of health care data (Dick and Steen, 1997). What
will this mean for the embodiment of future patients? Several authors argue that
we see a new form of subjectivity emerging: digital subjectivity. Rather than a
depth model of subjectivity, in which the raw and continuous essence of the
autonomous individual lies hidden deep under the surface, we will see the emerg-
ence of de-centered, dispersed and multiplied subjects. The surfaces of these new
subjects do not hide one essence but should rather be seen as displaying features
that happen to emerge out of running elementary codes that coincidentally
interact (Poster, 1990; Haraway, 1991; Hayles, 1998). Rather than subjects struc-
tured around one, lasting core, we are more like digital computers, whose seem-
ingly coherent and intelligent behaviors emerge out of interactions between
very simple basic units (ones and zeros; commands and routines). Where printing
culture and the book were core technologies constituting the liberal subject
described above (xing identities with deep structures), for these authors the
fragmented digital subject is produced, among other places, in the networks of
digital communication and virtual realities.
In our view, the merit of such claims would require much empirical (historical
and sociological/anthropological) work. It is much easier to suggest a trans-
formation in modes of subjectivity parallel to developments in our reading and
writing technologies than actually to demonstrate this shift. Whether other
aspects of embodiment will also be affected replacing physiology with genetics
as the master code? (Doyle, 1997) is even more an open question.
Notwithstanding these uncertainties, it does seem clear that modes of
36

subjectivity and/or embodiment are at stake in the ubiquitous introduction of
new, digital record-keeping systems. In the last section of this article, we briey
pointed at different modes of performing the patient as Subject even between
coexisting, paper-based record-keeping technologies. Here, we feel, lies an
important space for reection and intervention: if new, digital record-keeping
systems are currently being produced, and if the shape of such systems may affect
forms of embodiment, then the shaping of such systems becomes a politically
relevant matter. The sheer mundaneness and apparently technical nature of such
tools, again, makes it all too easy to overlook their political relevance. This, we
hope to have made clear, would be a big mistake.
Notes
We thank Emilie Gomart, Irma van der Ploeg, John Harley Warner, the participants at the CSI/WTMC
workshop Theorizing Bodies (Paris, 911 September 1998) and the two anonymous referees for their
comments and support.
1. The term dispositif is a perplexing one, a referee noted. It can be taken to mean the setting or
the context, which affords the existence or transformation of a phenomenon. Crucial is this perfor-
mative nature, and its heterogeneous constitution, as we elaborate in the following paragraph. These
two specications distinguish it from ordinary uses of terms like context and setting.
2. In an earlier article, Marc Berg and Geoff Bowker investigated the way current paper (and elec-
tronic) medical records can be seen to be a constitutive element of the patients body and of the body
politic of the hospital and the health care professions (1997).
3. The outlines of the 20th-century developments discussed in this article, however, seem to take
a roughly similar shape throughout the areas labeled as Western Medicine. In the United States, the
patient-centered record emerged faster and more comprehensively than elsewhere; yet whether this
has relevance for the other lines of our story would require additional investigation.
4. In this sense, this article builds upon the work of Barbara Duden (1991) and Katherine Hayles
(1992). Both studies are important attempts at trying to historize/contextualize the materiality and
experience of embodiment yet both authors maintain a distinction between the body (as objective
concept) and embodiment as a heuristic trope. For a comparable dissolution of the difference
between subjective and objective as the one proposed here see Latour (1997).
5. The study of the contemporary literature involved a thorough analysis of two core US medical
journals (the Journal of the American Medical Association, 190025) and the Boston Medical and
Surgical Journal (the predecessor of the New England Journal of Medicine, 190525) and of two
central US journals that focused on hospital organization and administration (Modern Hospital,
192035) and the Johns Hopkins Hospital Bulletin, 190530). Three Dutch and one English journal
were also analyzed for contrast and comparison: two Dutch hospital journals (Administratie en
Economie in de Ziekenhuizen, 19227, and Het Ziekenhuis, 191027, which was later called Het
Ziekenhuiswezen, 192833) and the two central medical journals of these countries (Nederlandsch
Tijdschrift voor Geneeskunde, 190740 and the Lancet, 191020). The precise start and end years of
the sample were decided according to the date that a journal was started, library availability and the
judgment (based upon quick scans of these volumes) that earlier or later issues would not add new
information. In addition, earlier articles, books or articles in different journals were sometimes picked
out when they were referenced in one of the articles selected through this literature search. A study

37
of original records would allow a deepening of many analytical points developed here. Access to
patients experiences could be found, for example, through an analysis of contemporary diaries or
literary sources. The purpose of this article, however, was as much a historical analysis as a concep-
tual, theoretical one and the material used here was well suited to these purposes.
6. The Mayo Clinic was unique in that it was a group practice yet even here all records were
individually kept.
7. What exactly this science would be, however, was far from clear (see, for example, Vogel and
Rosenberg, 1979; Warner, 1985; Rosenberg, 1987).
8. The case histories that Duden studied were much more extensive than these brief accounts. This
is in agreement with Warners analysis. Warner argues that patient narratives used to be longer in the
rst half of the 19th century (1986: 107).
9. A contemporary observer summarizes the Colleges criteria as follows:
A patient entering a hospital approved by the American College of Surgeons believes that he
is protected against fee-splitting doctors; that in this hospital there will be x-ray and labora-
tory facilities, and all the scientic equipment and apparatus necessary to treat the disease
with which he is aficted; that a clean, well lighted operating room with expert graduate
nurses in charge will be available if an operation is needed; that a complete record will be
kept of all the ndings and that they will be available if necessary for future reference.
(Hughes, 1932)
10. A record that would perform a more integrated patients body through forcing the records
user constantly to link current entries to patients active problems is Weeds problem-oriented record.
See Weed (1968); see also Berg (1997) for a discussion of Weeds views.
References
Anonymous (1909) The Advantage of Tabulating Clinical Records, Journal of the American Medical
Association 52: 389.
Anonymous (1914) Standardization in Hospital Records, Boston Medical and Surgical Journal 170:
63.
Anonymous (1918) Army Medical Records, Journal of the American Medical Association 70: 795.
Anonymous (1930) Uniform Hospital Reports Saves Time for the Record Departments, Modern
Hospital 34: 52.
Anonymous (1933) Admissibility of Hospital Records and Charts as Evidence, Modern Hospital 40:
82.
Armstrong, D. (1983) Political Anatomy of the Body: Medical Knowledge in Britain in the Twentieth
Century. Cambridge: Cambridge University Press.
Armstrong, D. (1985) Space and Time in British General Practice, Social Science and Medicine 20:
65966.
Atwater, E.C. (1989) Women, Surgeons, and Worthy Enterprise: The General Hospital Comes to
Upper New York State, in Diana Elizabeth Long and Janet Golden (eds) The American General
Hospital. Ithaca, NY and London: Cornell University Press.
Auchincloss, H. (ed.) (1926) Unit History System. New York and London: Garland Publishing Inc.
Berg, M. (1997) Rationalizing Medical Work: Decision Support Techniques and Medical Practices.
Cambridge, MA: MIT Press.
Berg, M. and G. Bowker (1997) The Multiple Bodies of the Medical Record: Towards a Sociology of
an Artifact, Sociological Quarterly 38: 51135.
Bottomley, J.T. (1918) Hospital Standardization Its Meaning, Boston Medical and Surgical Journal
179: 21923.
38

Bowker, G.C. and S.L. Star (1999) Sorting Things Out: Classication and Practice. Cambridge, MA:
MIT Press.
Braun, M. (1992) Picturing Time: The Work of Etienne-Jules Marey (18301904). Chicago: University
of Chicago Press.
Brotherhood, J.S. (1913) Hospital Clinical Records, Journal of the American Medical Association 60:
12059.
Brough, R.N. (1935) An Important Task Lies with the Record Librarian, Modern Hospital 44:
634.
Cartwright, L. (1995) Screening the Body: Tracing Medicines Visual Culture. Minneapolis: University
of Minnesota Press.
Clapesettle, H. (1954) The Doctors Mayo. Minneapolis: University of Minnesota Press.
Clinical Congress of Surgeons (1914) Report of the Committee on the Standardization of Hospitals,
Boston Medical and Surgical Journal 170: 713.
Craig, B.L. (19891990) Hospital Records and Record-keeping, c. 18501950 Part I: The Develop-
ment of Records in Hospitals, Archivaria 29: 5760.
Craig, B.L. (1990) Hospital Records and Record-keeping, c. 18501950 Part II: The Development
of Record-keeping in Hospitals, Archivaria 30: 2138.
Cussins, C. (1998) Ontological Choreography: Agency for Women Patients in an Infertility Clinic,
in M. Berg and A. Mol (eds) Differences in Medicine: Unraveling Practices, Techniques, and Bodies.
Durham, NC: Duke University Press.
Daston, L. and P. Galison (1992) The Image of Objectivity, Representations 40: 81129.
Dick, R.S. and E.B. Steen (eds) (1997) The Computer-based Patient Record: An Essential Technology
for Health Care. Washington, DC: National Academy Press.
Doyle, R. (1997) On Beyond Living: Rhetorical Transformations of the Life Sciences. Stanford, CA:
Stanford University Press.
Duden, B. (1991) The Woman Beneath the Skin: A Doctors Patients in Eighteenth-century Germany.
Cambridge, MA: Harvard University Press.
Eliot, C.W. (1906) The Future of the Medical Profession, Johns Hopkins Hospital Bulletin 17: 34750.
Foucault, M. (1963) Naissance de la clinique. Paris: Presses Universitaires de France.
Genevieve Morse, M. (1934) Hospital Case Records and the Record Librarian. Chicago: Physicians
Record Co.
Gomart, E. (2004) Surprised by Methadone: In Praise of Drug Substitution Treatment in a French
Clinic, Body & Society 10(23): 85110.
Haraway, D.J. (1991) The Biopolitics of Postmodern Bodies: Constitutions of Self in Immune
Systems Discourse, in Simians, Cyborgs, and Women: The Reinvention of Nature. New York:
Routledge.
Hayles, N.K. (1992) The Materiality of Informatics, Congurations 1: 14770.
Hayles, N.K. (1998) Transmigration and the Oreo: What Virtual Creatures Can Teach Us, paper
delivered at WTMC/CSI Conference, Maastricht.
Hayles, N.K. (1999) How We Became Posthuman: Virtual Bodies in Cybernetics, Literature and Infor-
matics. Chicago: University of Chicago Press.
Holmes, F.L. and K.M. Olesko (1995) The Images of Precision: Helmholtz and the Graphical Method
in Physiology, in N.M. Wise (ed.) The Values of Precision. Princeton, NJ: Princeton University
Press.
Howard, A.A. (1915) Hospital Efciency as Produced and Measured by a Follow-up System, Journal
of the American Medical Association 65: 19625.
Howell, J.D. (1995) Technology in the Hospital: Transforming Patient Care in the Early Twentieth
Century. Baltimore, MD: Johns Hopkins University Press.
Huffman, E.K. (1972) Medical Record Management. Illinois: Physicians Record Company.

39
Hughes, A.M. (1932) A Small Hospital Superintendent Explains Her Record System, Modern
Hospital 38: 957.
Jewson, N.D. (1976) The Disappearance of the Sick Man from Medical Cosmology, 17701870,
Sociology 10: 22544.
Kurland, L.T. and C.A. Molgaard (1981) The Patient Record in Epidemiology, Scientic American
245: 5463.
Latour, B. (1997) Trains of Thought: Piaget, Formalism, and the Fifth Dimension, Common
Knowledge 6: 17091.
Lawrence, C. (1985) Moderns and Ancients: The New Cardiology in Britain 18801930, Medical
History 40(Suppl. No. 5): 133.
Lewinski-Corwin, E.H. (1922) Medical Case Recording in Hospitals, Journal of the American
Medical Association 78: 6045.
Long, D.E. and J. Golden (1989) The American General Hospital. Ithaca, NY and London: Cornell
University Press.
Mol, A. (1998) Missing Links, Making Links: The Performance of Some Atherosclerosis, in M. Berg
and A. Mol (eds) Differences in Medicine: Unraveling Practices, Techniques and Bodies. Durham,
NC: Duke University Press.
Mol, A. (2003) The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University
Press.
Mol, A. and J. Law (2004) Embodied Action, Enacted Bodies: The Example of Hypoglycaemia, Body
& Society 103): 4362.
Munger, C.W. (1928) Hospital Case Records and Professional Standing Orders, Modern Hospital 30:
99106.
Ornstein, S.M., R.B. Oates and G.N. Fox (1992) The Computer-based Medical Record: Current
Status, Journal of Family Practice 35: 55665.
Pasveer, B. (1992) Shadows of Knowledge: Making a Representing Practice in Medicine: X-ray Pictures
and Pulmonary Tuberculosis, 18951930. Amsterdam: Universiteit van Amsterdam.
Pearl, R. (1921) Modern Methods in Handling Hospital Statistics, Johns Hopkins Hospital Bulletin
32: 18494.
Poster, M. (1990) The Mode of Information: Poststructuralism and Social Context. Chicago: University
of Chicago Press.
Reiser, S.J. (1978) Medicine and the Reign of Technology. Cambridge: Cambridge University Press.
Reiser, S.J. (1984) Creating Form Out of Mass: The Development of the Medical Record, in E.
Mendelsohn (ed.) Transformation and Tradition in the Sciences: Essays in Honor of I. Bernard
Cohen. New York: Cambridge University Press.
Reiser, S.J. (1991a) The Clinical Record in Medicine, Part 1: Learning from Cases, Annals of Internal
Medicine 114: 9027.
Reiser, S.J. (1991b) The Clinical Record in Medicine, Part 2: Reforming Content and Purpose, Annals
of Internal Medicine 114: 9805.
Reverby, S. (1981) Stealing the Golden Eggs: Ernest Amory Codman and the Science and Manage-
ment of Medicine, Bulletin of the History of Medicine 55: 15671.
Rosenberg, C.E. (1987) The Care of Strangers: The Rise of Americas Hospital System. New York:
Basic Books.
Slobe, F.W. (1923) Applying Minimal Standards to Hospitals, Modern Hospital 20: 1668.
Smith, D. (1990) Texts, Facts, and Femininity: Exploring the Relations of Ruling. London: Routledge.
Starr, P. (1982) The Social Transformation of American Medicine. New York: Basic Books.
Stevens, H.P. (1919) Case Records and Histories in the Smaller Hospitals, Boston Medical and
Surgical Journal 181: 3249.
Stevens, R. (1989) In Sickness and in Wealth: American Hospitals in the Twentieth Century. New York:
Basic Books.
40

Stokes, J.H., R.A. Kern and L.K. Ferguson (1933) What Sixty-six Hospitals Think of the Central Unit
Record System, Modern Hospital 40: 8792.
Thomson, A.N. (1920) Individual Treatment Record Transient, Modern Hospital 15: 2301.
Vogel, M.J. and C.E. Rosenberg (ed.) (1979) The Therapeutic Revolution: Essays in the Social History
of American Medicine. Philadelphia: University of Pennsylvania Press.
de Vries, G.H., K. Horstman and O. Haveman (1997) Politiek van preventie. Normatieve aspecten van
voorspellende geneeskunde. Den Haag: Rathenau Instituut.
Wallace, G.B. (1922) Discussion on Medical Case Recording in Hospitals, Journal of the American
Medical Association 78: 6045.
Warner, J.H. (1985) Science in Medicine, Osiris 1 (2nd series): 3758.
Warner, J.H. (1986) The Therapeutic Perspective: Medical Practice, Knowledge and Identity in
America, 18201885. Cambridge, MA: Harvard University Press.
Waters, K.A. and G.F. Murphy (1979) Medical Records in Health Information. Germantown, MD:
Aspen Systems Corporation.
Weed, L.L. (1968) Medical Records that Guide and Teach, New England Journal of Medicine 278:
593600, 6527.
Whiting Myers, G. (1932) How the Record Librarian Serves Three Masters Impartially, Modern
Hospital 39: 646.
Yates, J. (1989) Control through Communication: The Rise of System in American Management.
Baltimore, MD: Johns Hopkins University Press.
Marc Berg is Professor and Chair of the Department of Social-Medical Sciences at the Institute of
Health Policy and Management, Erasmus University Rotterdam, The Netherlands. He has published
widely in the eld of medical sociology, science and technology studies and information sciences,
focusing on the role of information technologies and rationalization projects in medical work. Core
publications include Rationalizing Medical Work. Decision Support Techniques and Medical Practices
(Cambridge, MA: MIT Press, 1997); Differences in Medicine. Unraveling Practices, Techniques and
Bodies (with Annemarie Mol; Durham, NC: Duke University Press, 1998), and Orders and Their
Disorders: On the Construction of Universalities in Medical Work (Congurations 8, 2000).
At the time of writing, Paul Harterink was a junior researcher at the Department of Health Ethics
and Philosophy at the University of Maastricht, The Netherlands.

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