On the History of Disease-Concepts: The Case of Pleurisy

Fleck L. , Entstehung und Entwicklung einer wissenschaftlichen Tatsache: Einführung in die Lehre vom Denkstil und Denkkollektiv (Basel, 1935); Genesis and development of a scientific fact (transl. by Bradley F. Trenn T. J. , ed. by Trenn T. J. Merton R. K. , Chicago, 1979).

Temkin O. , The Falling Sickness: A history of epilepsy from the Greeks to the beginnings of modern neurology (Baltimore, 1945). On the limits of Temkin's vision see below, at ref. 40.

Canguilhem G. , Le normal et le pathologique (Paris, 1966); The normal and the pathological (transl. by Fawcett C. R. Cohen R. S. , Dordrecht, 1978; New York, 1991). On the enduring relevance of Canguilhem's work see Nicolson M. , “The social and the cognitive: Resources for the sociology of scientific knowledge”, Studies in history and philosophy of science, xx (1991), 347–69.

Figlio K. , “Chlorosis and chronic disease in nineteenth-century Britain: The social construction of somatic illness in a capitalist society”, Social history, iii (1978), 167–97 (cf. below, at ref. 53); Wright P. Treacher A. (eds), The problem of medical knowledge: Examining the social construction of medicine (Edinburgh, 1982).

For instance Pelling M. , Cholera, fever and English medicine 1825–1865 (Oxford, 1978); Jarcho S. , The concept of heart failure: From Avicenna to Albertini (Cambridge, Mass., 1980); Bynum W. F. Nutton V. (eds), Theories of fever from Antiquity to the Enlightenment (Medical history Supplement no. 1, London, 1981); Maulitz R. C. , Morbid appearances: The anatomy of pathology in the early nineteenth century (Cambridge, 1987); Smith W. D. , “Pleuritis in the Hippocratic Corpus and after”, Proceedings of the Sixth International Hippocratic Colloquium, Quebec, September 1987 (Quebec City, 1989); Nicolson M. McLaughlin C. , “Social constructionism and medical sociology: A study of the vascular theories of multiple sclerosis”, Sociology of health and illness, x (1988), 234–61.

For a helpful conspectus and a guide to recent literature see Bynum W. F. Porter R. (eds), Companion encyclopedia of the history of medicine (2 vols, London, 1993), Part III (vol. i), particularly the essays by Pelling M. Wilson L. G. Olby R. C. Brown T. M. Worboys M. Cantor D. Porter R. (chaps. 16, 19–21, 24–25, 27). (The Companion encyclopedia, it should be remarked, is exceptional amongst recent textbooks in the attention it devotes to this theme.) See also Maulitz R. C. , “In the clinic: Framing disease at the Paris hospital”, Annals of science, xlvii (1990), 127–37; essays of Lawrence C. Peitzman S. , cited in refs 15, 18 below; and Duffin J. , To see with a better eye: A life of R. T. H. Laennec (Princeton, N.J., 1998).

On what “chlorosis” meant in relation to twentieth-century categories see Loudon I. , “The diseases called chlorosis”, Psychological medicine, xliv (1984), 27–36.

See for instance Gilman S. L. , Hysteria beyond Freud (Berkeley, 1993).

Fleck , Genesis and development of a scientific fact (ref. 1), 1–19.

The corollary was that in Fleck's view, “Spirochaeta pallida should … be defined by syphilis rather than the other way around” (ibid., 18).

Ibid., 14, my emphasis.

“The relation between the Wassermann reaction and syphilis — An undoubted fact” entailed “several adaptations and transformations of concepts”: ibid., 97–98, Fleck's emphases. See also the extended discussion in note 5 (pp. 178–9) to p. 102.

Ibid., 39.

Gabbay J. , “Asthma attacked? Tactics for the reconstruction of a disease concept”, in Wright Treacher (eds), The problem of medical knowledge (ref. 4), 23–48.

Lawrence C. , ‘“Definite and material’: Coronary thrombosis and cardiologists in the 1920s”, in Rosenberg C. Golden J. (eds), Framing disease: Studies in cultural history (New Brunswick, N.J., 1992), 50–82.

See the remarks of Paul White in 1931, quoted by Lawrence, ‘“Definite and material’”, 67.

At least, so far as this has been traced — For the loose end left by Lawrence's study is the question as to how “consensus” over the ECG was reached (ibid., 72).

Peitzman S. J. , “From Bright's disease to end-state renal disease”, in Rosenberg Golden (eds), Framing disease (ref. 15), 3–19.

Ibid., 9, 11, 16.

The most notable exception is Cunningham A. , “Transforming plague: The laboratory and the identity of infectious disease”, in Cunningham A. Williams P. (eds), The laboratory revolution in medicine (Cambridge, 1992), 209–44.

Quétel C. , Le Mal de Naples (Paris, 1986); History of syphilis (transl. by Braddock J. Pike B. , Cambridge, 1990). “Syphilis as a cultural phenomenon” is the title of the introduction (pp. 1–8).

Ibid., 53, 67, 75, 81, 108.

This from the Oxford English dictionary — For characteristically, Le Mal de Naples does not mention the meaning of the term.

“Thus syphilis came to be recognised as syphilis, gonorrhoea as gonorrhoea” ( Quétel , Le Mal de Naples (ref. 21), 111). Cf. and contrast Fleck, Genesis and development of a scientific fact (ref. 1), 7–8.

The point is touched upon just once and in passing: Quétel, Le Mal de Naples (ref. 21), 97.

Fleck , Genesis and development of a scientific fact (ref. 1), 41. See also, for instance, pp. 15–16 (“The discovery of the causative agent, Spirochaeta pallida, was the result of steady, logical work by civil servants”), 22, 69–70. For a general formulation see p. 123: “the true creator of a new idea is not the individual but the collective.”.

Ibid., 98.

Ibid., 99.

These mechanisms involved a spectrum of communication-media, from what Fleck called “journal science”, through “vademecum science” and “textbook science”, to “popular science”: See ibid. , 111–25. At one extreme, “journal science”, which is precisely the “vanguard” of science (p. 123), is “provisional, uncertain, and personally colored” (p. 119); at the opposite extreme, “popular science” entails “valuation” (p. 113), “simplicity” and “vividness” (p. 115). The key intermediate category was “vademecum science” (pp. 119–24), which represents the “collective, generally valid” aspect of research science (p. 120), and “requires a critical synopsis in an organized system” (p. 118, Fleck's emphasis); on this see refs 31, 34 below.

Ibid., 112.

Ibid., 122–3. Here I am simplifying Fleck's picture, for at this point he was in fact discussing “vademecum science” rather than “popular science”. However this simplification is not inappropriate, for three reasons. In the first place, Fleck argued that popular science has a “general epistemological significance”, since its qualities of “certainty, simplicity, vividness” are precisely the goals of “the expert” as well (pp. 114–15) — Whence the fact that “the conviction that there is no development of thought”, which as we see below is characteristic of popular science, is “a conviction that also influences the expert” (p. 116). Secondly, vademecum science and popular science as Fleck depicted these have many features in common: For instance, vademecum science resembles popular science in seeking to constitute a “closed system” (p. 119); in involving “exoteric” as well as “esoteric” knowledge (p. 123); and in constructing a mythical, individualized history (pp. 122–3; cf. p. 116, as quoted immediately below). Third, Fleck described vademecum science as developing out of “journal science” through processes of communication, including the stabilizing of nomenclature (pp. 120–3); and he had already insisted that “Every communication and, indeed, all nomenclature tends to make any item of knowledge more collective and popular” (p. 114, Fleck's emphasis). See also ref. 34 below.

Ibid., 116 (here referring to “popular science” itself).

On the same page Fleck reproduced a potted history of syphilis (from Gottstein's book of 1929) and commented: “From descriptions such as this, the conviction emerges that there is no development of thought.”.

Ibid., 120–1. Strictly speaking, this anecdote concerning retrospective diagnosis was presented not as an aspect of “popular science” but rather within Fleck's account of “vademecum science”, and not as a characteristic of such science but rather for a specific technical reason (i.e., as an illustration of the collective, “impersonal”, origin of collectively-accepted concepts). But my appropriation of Fleck's brief discussion of retrospective diagnosis is, I submit, consistent with the claims he had already made about the apprehension of “syphilis” in “popular science” (p. 116). See also ref. 31 above.

Ibid., 82–83, 165.

Ibid., 140; cf. p. 111 (ref. 24 above).

For a rare exception whose very brevity confirms the rule, see ibid., 5–6.

Above, at ref. 20.

For example, the main reference work on the history of science cites Fleck's work three times, in each case as a major conceptual resource, whereas the comparable (and substantially longer) reference work on the history of medicine refers to Fleck only once, and even then as what amounts to an addendum on the history of Fleck's own field, immunology. See respectively Olby R. C. Cantor G. N. Christie J. R. R. Hodge M. J. S. (eds), Companion to the history of modern science (London, 1990), 64, 91, 164, and Bynum Porter (eds), Companion encyclopedia of the history of medicine (ref. 6), 203. Even Cunningham's fine essay “Transforming plague” (ref. 20 above), the central historiographic point of which is entirely consonant with Fleck's approach, does not cite Fleck. Fleck was first noticed in English by Kuhn T. S. , The structure of scientific revolutions (Chicago, 1962), pp. vi–vii; the 1979 English translation was produced at the behest of historians and sociologists of science, notably R. Merton.

See for instance Brieger G. , “The historiography of medicine”, in Bynum Porter (eds), Companion encyclopedia of the history of medicine (ref. 6), i, 24–44, p. 31.

Temkin , The Falling Sickness (ref. 2), Preface, p. vii, my emphasis.

Koch R. , The aetiology of tuberculosis (German original 1882; transl. by Pinner M. Dr, Mrs , New York, 1932), 44. Tuberculosis was originally “consumption” or “phthisis” (touched upon in refs 110 and 194 below); Koch's redefinition of the disease transformed its meaning in complex ways, precisely in line with what Fleck was to write about syphilis (above, at ref. 13).

Foucault M. , Naissance de la clinique (Paris, 1963); Birth of the clinic: An archaeology of medical perception (transl. by Smith A. M. Sheridan , London, 1973).

See for instance Armstrong D. , Political anatomy of the body: Medical knowledge in Britain in the twentieth century (Cambridge, 1983).

Foucault , Birth of the clinic (ref. 43), pp. x, xv, xi.

For “imaginary investments” see ibid., p. x.

Mutatis mutandis, the same is true of N. Jewson's classic study, “Medical knowledge and the patronage system in eighteenth-century England”, Sociology, viii (1974), 369–85.

Foucault , Birth of the clinic (ref. 43), p. xi.

Ibid., p. xi; my emphasis.

Ibid., pp. xvi–xvii.

Ibid., 196, p. xii; my emphases.

Thus for all that Foucault consistently distanced himself from structuralism, his archaeological oeuvre is open to precisely the kind of critique that P. de Man levelled at structuralism in various of his works; see for instance Blindness and insight: Essays in the rhetoric of contemporary criticism (first edn, 1971; revised edn, London, 1983); Allegories of reading: Figural language in Rousseau, Nietzsche, Rilke and Proust (New Haven, 1979); and The resistance to theory (ed. by Godzich W. , Minneapolis, 1986). See further the penetrating discussion of Foucault in Burke S. , The death and return of the author: Criticism and subjectivity in Barthes, Foucault and Derrida (Edinburgh, 1992; 2nd edn, 1998).

Figlio , “Chlorosis and chronic disease in nineteenth-century Britain” (ref. 4).

Ibid., 173–5.

Ibid., 175.

Ibid., 193.

See respectively pp. 178 nn. 32, 34; 181; 185; 174 n. 21; and many subsequent citations (Black's medical dictionary).

Ibid., 174–5.

See for instance ibid., 179: “Constructing the illness … was the other face of discovering adolescence.”.

Notably at ibid., 177–8, invoking Laslett's argument that the age of menarche declined in the nineteenth century.

See for instance de Sauvages F. Boissier , Nosologia methodica sistens morborum classes juxta Sydenhami mentem and botanicorum ordinem (2 vols, Amsterdam, 1768), ii, 440–3.

Garrison F. H. Morton L. T. , A medical bibliography: An annotated check-list of texts illustrating the history of medicine (4th edn, Aldershot, 1983), 418–19.

Rosenberg Golden (eds), Framing disease (ref. 15).

Rosenberg Charles E. , “Framing disease: Illness, society, and history”, ibid., pp. xiii–xxvi, at pp. xiv–xv.

Cf. above, at ref. 42. On the shifting meanings of “cholera” and on the problems attending retrospective diagnosis of “tuberculosis”, see Grmek M. , Diseases in the ancient Greek world (transl. by Muellner M. Muellner L. , Baltimore, 1989), 7, 183–4. The latter work, it should be observed in passing, has an ambiguous significance in relation to my theme. On the one hand, it rests entirely upon retrospective diagnosis and pays little attention to ancient disease-concepts — Thereby participating in the naturalist-realist tradition. On the other hand, Grmek stresses throughout (for instance, in the passages just cited) that modern concepts of disease are incommensurate with ancient ones — This in harmony with the historicalist-conceptualist approach.

See further Rosenberg, “Framing disease” (ref. 64), p. xvi, where this anti-relativist position was reiterated. Here the argument became rather more complicated, for Rosenberg rightly argued that “the process of disease definition” merited attention, thereby seemingly abandoning the framing metaphor. See also ref. 68 below.

For instance an essay on silicosis, bearing the promising title “The illusion of medical certainty”, nevertheless began by asserting — With no intended irony — That “Silicosis is a chronic lung disease caused by the inhalation of silica dust”. Markowitz G. Rosner D. , “The illusion of medical certainty: Silicosis and the politics of industrial disability, 1930–1960”, in Rosenberg Golden (eds), Framing disease (ref. 63), 185–205.

Similarly, when introducing Peitzman's essay Rosenberg summarized its argument by saying that “the evolving framework of pathological assumptions describing and explaining ‘Bright's disease’ has been gradually integrated and reintegrated into a series of differently focused explanatory frameworks for the same clinical pictures” (my emphasis), and remarked that “It is precisely this process of definition and redefinition that demands scholarly attention”. Here the initial assumption of clinical constancy, associated again with the metaphor of framing-and-pictures, was immediately (and commendably) undermined by the notion of “definition and redefinition”. See Rosenberg Golden (eds), Framing disease (ref. 63), 4, and cf. ref. 66 above.

Until recently an analogous situation obtained within the sociology of medicine, the scope of which was traditionally restricted by giving a particular twist to the supposed distinction between “illness” and “disease”. “Illnesses”, it was said, were the subjective experiences of patients; they fell within the realm of “culture”, and were therefore seen as forming a proper theme for sociological inquiry. “Diseases”, in contrast, were conceived as real pathological processes, taken to coincide with their (supposed) medical definitions; they were regarded as inhabiting the realm of “nature”, and therefore as lying beyond the bounds of sociological investigation. For this point, and for a cogent argument against this framework of assumptions, see Atkinson P. , Medical talk and medical work: The liturgy of the clinic (London, 1995), chap. 2. The burden of Atkinson's argument is that just as diseases are the constructs of medicine, so the supposed objectivity of those diseases was the construct of traditional medical sociology itself. Like Rosenberg, Atkinson has deliberately avoided the term “construction”; but significantly, he replaces it not by “framing” but instead by “production” (ibid., 45); and unlike Rosenberg, he refers to Fleck (pp. 143, 147). Similar points had already been made, from a rather different perspective (concerned with the sociology of illness rather than the sociology of knowledge), by Dingwall R. , Aspects of illness (London, 1976), chap. 2. As for the “illness”/“disease” distinction, both words are so elastic that it can be made in many different ways, or avoided altogether, according to one's rhetorical purposes: See Caplan A. L. Engelhardt H. T. Jr McCartney J. M. (eds), Concepts of health and illness: Interdisciplinary perspectives (Reading, Mass., 1981), and Currer C. Stacey M. (eds), Concepts of health and illness and disease: A comparative perspective (Leamington Spa, 1986).

Shapin S. , “History of science and its sociological reconstructions”, History of science, xx (1982), 157–211, p. 157.

Smith , “Pleuritis” (ref. 5). I thank Professor Smith for e-mailing me a copy of this paper and of his translations from the ancient texts, and for helpfully discussing my various queries.

Foucault , Birth of the clinic (ref. 43), 122.

Smith , “Pleuritis”, quoted here from typescript.

Particularly the Aphorisms (below, at ref. 121).

Regimen in acute diseases (below, at ref. 123).

This was the thrust of the discussions of pleuritis in Diseases I (the work known to Galen as Internal suppurations): 26 and in Places in man: 14. See respectively the Loeb edn, Hippocrates , v (transl. by Potter P. , London, 1988), 98–183, pp. 166–71, and Smith , “Pleuritis” (ref. 5), Appendix. This aspect also appeared in Affections: 7, which however was one of the texts that did define pleuritis, as next discussed.

Affections : 7. See Loeb edn, Hippocrates, v, 6–91, pp. 15–16.

Diseases II : 44–46. See Loeb edn, Hippocrates, v, 191–333, pp. 262–7.

Diseases III : 16. See Loeb edn, Hippocrates, vi (transl. by Potter P. , London, 1988), 6–63, pp. 38–57.

Ibid., 38–39; Smith's translation, in the appendix to his “Pleuritis” (ref. 5).

Loeb edition, Hippocrates, vi, “Index of symptoms and diseases”, 336.

Ibid., translator's note, 334.

Diseases I and Places in man, as cited in ref. 76 above; Aphorisms, quoted below, at ref. 121.

See below, at ref. 123; Smith , “Pleuritis” (ref. 5), 3–4; and Jacquart D. , “Theory, everyday practice, and three 15th-century physicians”, Osiris, 2nd ser., vi (1990), 140–60, p. 154.

Below, at ref. 87.

Here my reading differs from that of Smith, “Pleuritis”, who characterizes Diseases III as discussing “a single disease with various manifestations”.

Diseases II: 44–46 (Loeb edn, Hippocrates, v, 264–7); cf. above, at ref. 85.

In one text only, namely Places in man: 14, pleuritis was given an internal anatomical location, specifically in the lung. This work was also unique in conceiving pleuritis as the one-sided version of peripneumony: “When both sides are painful and the affections of both sides are similar, that is peripneumony; the other is pleuritis” (Smith's translation, “Pleuritis” (ref. 5), Appendix). Although many of the Hippocratic texts discussed pleuritis and peripneumony in sequence and offered overlapping therapies for them, they usually defined them in quite different ways. In particular, pleuritis was always defined with reference to pain in the side, as we have seen; but the defining symptoms of peripneumony were fever, cough and expectoration, with pain being mentioned only erratically. In short, the entire thrust of the discussion of pleuritis and peripneumony in Places in man was well outside the Hippocratic mainstream. (Accounts of peripneumony appeared in Affections: 9, Diseases I: 27, and Diseases II: 47, all in Loeb edn, Hippocrates, v; see pp. 17, 171, 267–9.).

Traditionally, Praxagoras is regarded as the teacher of Herophilus. With respect to the localization of pleuritis, Diocles may well have preceded Erasistratus, though this is not to say that he was Erasistratus's teacher. The possible roles of Praxagoras and (especially) Diocles in the story of pleuritis are discussed by Smith , “Pleuritis” (ref. 5); here, however, as a convenient simplification, I shall depict the anatomical tradition as stemming from Herophilus and Erasistratus, setting aside Praxagoras and Diocles. (The views of Diocles and Praxagoras on peripneumony are quoted in ref. 92 below.).

Aurelianus Caelius , Acute diseases , II.xiii–xxiv, in Drabkin I. E. (ed. and transl.), Caelius Aurelianus: On acute diseases and On chronic diseases (Chicago, 1950), 181–227, chap. 16 (pp. 189–93). In fact, my claim that the dogmatics “defined” pleuritis in anatomical terms is a projection backwards from stage (iii) of ancient medicine (see below, particularly the discussion of Aretaeus at ref. 115); strictly speaking, it is possible that the dogmatics defined pleuritis in symptomatic terms and added an anatomical seat (or rather, seats). But for convenience I am eliding this particular subtlety.

On peripneumony cf. ref. 88 above.

“In the case of people suffering from peripneumonia, Diocles says the veins of the lung are affected, while Erasistratus says the arteries are affected, and Praxagoras the parts of the lung which are joined to the spine. But Herophilus says the whole lung is affected. If the patients [also] suffer from fever, he says, it causes pleurisy.” Caelius Aurelianus, quoted in von Staden H. , Herophilus: The art of medicine in early Alexandria (Cambridge, 1989), 378 (T.215). Cf. Caelius Aurelianus, Acute diseases, ed. by Drabkin (ref. 90), II.xxviii (p. 231).

This emerges from a passage from Galen's De locis affectis, as discussed by Smith in “Pleuritis” (ref. 5).

Aurelianus Caelius , Acute diseases, ed. by Drabkin (ref. 90), II.xiv [91] and II.xvi [96–98] (pp. 185, 189–91).

With a interesting qualification: That those who placed pleuritis in the membrane, or some of them, apparently believed that “some patients find it impossible to lie on the side affected, while others, on the contrary, rest more easily on that side”: ibid., II.xvi [98] (p. 191). To complicate the matter, the justifying argument does not match the claim itself, as Drabkin observes in an editorial footnote. This very issue would be revived by Morgagni: See below, at ref. 176.

Ibid., II.xvi [96] (p. 189).

Ibid., II.xvi [98] (p. 191). Also of interest is the passage which records the views of Soranus/Caelius himself, for here there emerged an additional dimension of this symptom, one which I have not encountered in any other text: “when they turn on the opposite side they experience pain and actually feel the inflamed organs hanging and being drawn down by their own weight”: Ibid., II.xiv [91] (p. 185), emphasis added.

Aurelianus Caelius , Acute diseases, ed. by Drabkin ; at ref. 73 on p. 284.

Cited below, from ref. 120 onwards.

Aretaeus , On the causes and symptoms of acute diseases , in Adams F. (ed. and transl.), The extant works of Aretaeus, the Cappadocian (London, 1856).

For the original Greek and Latin words see Drabkin's introduction (ibid., pp. xi–xxvi, at p. xix).

In the case of cardiac disease Soranus/Caelius was anti-localist (ibid., II.xxxiv, 257–61, p. 259); with respect to hydrophobia, he adopted an intermediate position (III.xiv, 371–5, pp. 374–5).

Ibid., II.xvi [100] (p. 193).

It should be mentioned, however, that Soranus's (Caelius's) citations of Hippocrates were somewhat haphazard and erratic: See ibid., Drabkin's note 1, p. 62 and note 10, p. 353.

Ibid., II.xix [113–24] (203–15).

Smith , “Pleuritis” (ref. 5), 5.

Ibid., 6–7.

“Stimulosus ac pulsuosus et igneus“: Caelius Aurelianus, Acute diseases, ed. by Drabkin (ref. 90), II.xiv [91], 184.

‘Nygmatodes’ () is so translated in Durling R. J. , A dictionary of medical terms in Galen (Leiden, 1993).

The tricky issue concerns the term ‘nygmatodes’, used by Galen to characterize the pains of pleuritis. Aretaeus also used this word in connection with pleuritis, but he did so not in his generic description of the disease but rather as a sign that it had progressed to empyema: See Aretaeus , Acute diseases , ed. by Adams (ref. 100), I.x, 17 (Greek), 257 (English). Thus for Aretaeus, pains of the “nygmatodes” type were in fact characteristic not of pleuritis, but of empyema. And it would appear that Soranus had done something similar; for in Caelius Aurelianus's Latin rendition, he wrote that the transition from pleuritis to empyema is associated with “pungent pains” (dolore pungenti), as distinct from the pain of pleuritis itself, which in this particular context he described not as “pungent” but merely as “acute” (dolor acutus): See Aurelianus Caelius , Acute diseases , ed. by Drabkin (ref. 90), II.xvii [101–2] (p. 194). If (as later usages indeed imply) the Latin pungens was equivalent to the Greek nygmatodes, then the account of Soranus/Caelius differs from that of Galen much as that of Aretaeus does.

See above, at ref. 86.

On Archigenes see further below, at ref. 128.

This is Wesley Smith's interpretation. The matter is complicated by the relation between the “pricking” quality of the pain and the progression of pleuritis to empyema: See ref. 110 above.

Immediately after announcing the conclusion that “it is the hypezocos membrana which is the seat of this disease”, Soranus/Caelius added: “And this membrane is the source of severe pains (dolorem vehementem), for it is fibrous and attached to the side.” This came within a passage framed as a summary of the views of those who place pleuritis in the “hypezocos membrana”, which indicates that Soranus/Caelius was here paraphrasing Erasistratus et al. See Aurelianus Caelius , Acute diseases, ed. by Drabkin (ref. 90), II.xvi [98–100] (pp. 191–3).

Aretaeus , Acute diseases, I.x, ed. by Adams (ref. 100), 16, 255–6; word-order modified slightly.

This with the phrase “all these symptoms”, in the third sentence.

Foucault , Birth of the clinic (ref. 43), 137; Cunningham A. , “Getting the game right: Some plain words on the identity and invention of science”, Studies in history and philosophy of science, xix (1988), 365–89, pp. 373–5.

Cf. Heidegger M. , Being and time (German original 1928; transl. from the 7th German edition by J. Macquarrie and E. Robinson, Oxford, 1962), section 7, p. 52, and below, at ref. 122.

See Smith W. D. , The Hippocratic tradition (Ithaca, N.Y., 1979). For a different reading see Longrigg J. , Greek rational medicine: Philosophy and medicine from Alcmaeon to the Alexandrians (London, 1993).

Aphorisms, V.viii (cf. also xv), in Loeb edn, Hippocrates , iv (transl. by Jones W. H. S. , London, 1931), 98–221, p. 159; Galen , Commentary on Hippocrates' Aphorisms (17B 399 K.), as cited and translated by Smith , “Pleuritis” (ref. 5).

Contrast the translation in Lloyd G. E. R. (ed.), Hippocratic writings (Harmondsworth, 1978/1983), 222: “If sufferers from pleurisy do not cough up material within fourteen days, the inflammation produces empyema.” The “inflammation” here appears to have been interpolated by the translators (J. Chadwick and W. N. Mann). On the transition of pleuritis to empyema, compare Aretaeus's discussion (ref. 110 above).

Although certain of the Hippocratic texts had speculated as to the internal events underlying pleuritis (see above, at ref. 76), they had not installed these posited internal events as definitive of the disease; rather, the disease was identified as its symptoms. Hence the fact that those symptoms were never turned into “signs”; nor indeed were they conceived as “symptoms” in our sense (cf. above, at ref. 118), for they lay on the same ontological level as the disease.

Hippocrates , Regimen in acute diseases: 16, in Loeb edn, Hippocrates, ii (transl. by Jones W. H. S. , London, 1923), 75; Galen , Commentary on Regimen in acute diseases (15.488 K), as cited and translated by Smith , “Pleuritis” (ref. 5).

Smith , “Pleuritis” (ref. 5) discusses several of these passages.

Galen , De causis pulsuum, IV.viii, in Blondel F. Le Moine A. (eds), Hippocratis Coi, et Claudii Galeni Pergameni archiatron opera (13 vols in 9, Paris, 1639–89), viii, 223–5; De praesagitatione ex pulsibus, IV, ibid. , 298–9; De pulsibus ad tyrones, cap. xii, ibid. , 8–9; Galeni Synopsis librorum suorum de pulsibus, ibid., 326.

So we may infer from the fact that the Soranus/Caelius passage cited earlier (above, at ref. 90) made no mention of the pulse in connection with the dispute over the localization of pleuritis.

See von Staden , Herophilus (ref. 92), 262–88. All observers credited Herophilus with the basic pulse-nomenclature, but none of them mentioned the “hard” pulse (or its opposite, the “soft” pulse) amongst the various terms he had developed.

It seems that the terms “hard” and “soft” pulse were introduced by Archigenes (see Galen , De pulsuum differentiis, III.vii, in Blondel Le Moine (eds), Hippocratis et Galeni opera (ref. 125), viii, 77–79); but it is unclear whether Archigenes had applied these terms to the particular cases of pleurisy and peripneumony. On Galen's debts to Archigenes in respect of pulse-lore, see von Staden , Herophilus (ref. 92), 284 n.156; on Archigenes and pleuritis see above, at ref. 112.

Galen , De causis pulsuum, IV.xii, in Blondel Le Moine (eds), Hippocratis et Galeni opera (ref. 125), viii, 227; De pulsibus ad Tyrones, cap. xii, in ibid., 10.

Galen , De causis pulsuum, IV.viii, in ibid. , viii, 224.

Ibid., viii, 223.

Saunders J. B. O'Malley C. D. , Andreas Vesalius Bruxellensis, The Bloodletting Letter of 1539: An annotated translation and study of Vesalius's scientific development (New York, 1946), 15. See also Cunningham A. , The anatomical renaissance: The resurrection of the anatomical projects of the ancients (London, 1997), 101–2, 110–11. The issue had medieval precedents: See Jacquart , “Theory, everyday practice, and three 15th-century physicians” (ref. 84), 158.

Saunders O'Malley , The Bloodletting Letter (ref. 132), 74.

Ibid., 81–82; cf. ref. 136 below.

Ibid., 70, reading “pleuritis” for “pleurisy” throughout.

The membrane did enter Vesalius's discussion at a later point ( ibid. , 81–82), but not as the seat of the disease; rather, to demonstrate that dolor lateralis tends most often to occur where that membrane is “less firmly attached”, that is, in the vicinity of the fifth to the eighth ribs. See further ref. 144 below.

Cunningham , The anatomical renaissance (ref. 132), 124.

Cf. ibid., 102.

Cf. Saunders O'Malley , The Bloodletting Letter (ref. 132), 8, and ref. 144 below.

This in a later text, from 1546; see ref. 144 below.

Immediately after the passage just quoted Vesalius remarked: “In addition the name pleurisy derived from the ribs — Also called , because they form the side — By no means indicates a primary position, since the ancient Latin writers called the disease dolor lateralis, not dolor costalis…” ( Saunders O'Malley , The Bloodletting Letter (ref. 132), 70; here I have modified the translation and punctuation for greater clarity).

A strong contender was Mondino dei Liuzzi: See Jacquart , “Theory, everyday practice, and three 15th-century physicians” (ref. 84), 156.

Cf. Lloyd G. E. R. , “The development of Greek anatomical terminology”, in his Science, folklore and ideology: Studies in the life sciences in ancient Greece (Cambridge, 1983), 149–67.

Vesalius , De humani corporis fabrica, VI.ii. A few years later (1546), in the course of his Epistola rationem modumque propinandi radicis Chynae decocti (Letter on the China root), Vesalius returned in passing to the topic of pleurisy, mentioning two fatal cases, each of which he had examined post mortem. The first case (in which the patient was said to have died of “dolor lateralis”) seems at first sight to embody a shift from Vesalius's views of 1539, for this showed inflammation of the membrana costas succingens on the left side. But the second case (described as “morbus lateralis”) suggests that his conception was unchanged, for here the inflammation was not tied to that membrane, but rather “occupied the whole posterior part of the thorax” and followed the distribution of the unpaired vein. Combining the two cases, we may infer that Vesalius regarded the succingens membrane as just one possible seat of “dolor lateralis” or “morbus lateralis”, a view which harmonized perfectly with what he had written in 1539. Nevertheless it is worth remarking that both these post-mortems showed inflammation, whereas in 1539 Vesalius had mentioned only an “affection”; it is not clear whether this represents a change in his views or whether it was merely a matter of verbal tactics. See Vesalius , Opera omnia anatomica et chururgica , ed. by Boerhaave H. Albinus B. S. (2 vols, Leyden, 1725), ii, 664, and Morgagni , The seats and causes of diseases (ref. 169), 623.

See Whitteridge G. (ed.), The anatomical lectures of William Harvey (Edinburgh, 1964), 236, 246. When William Harvey lectured on anatomy in 1616, taking Bauhin as his starting-point, he accepted this use of “pleura”. (Incidentally, Bauhin also used “pleura” in a quite different way: As a designation for fibrous bands connecting the lungs to the chest wall. Harvey contested Bauhin's assumption that such fibrous bands were normal, but he did not dispute this further use of the term “pleura”: See ibid., 275.).

Ibid., 236; Cunningham , The anatomical renaissance (ref. 132), 103.

Baglivi G. , The practice of physick, reduc'd to the ancient way of observations. Containing a just parallel between the wisdom and experience of the Ancients, and the hypothesis's of modern physicians. Intermix'd with many practical remarks upon most distempers (transl. anon., London, 1723), chaps. 9 and 103.

Cunningham , The anatomical renaissance (ref. 132), chap. 4.

Baglivi , The practice of physic (ref. 147), 2, 120–1.

Ibid., passim, esp. pp. 20–21, 115–16.

Ibid., 60. Cf. also pp. 103, 104 (“scattered sentences”, “snug sentences”).

Ibid., 59.

Ibid., 103, 60.

Ibid., 105.

See Bacon F. , The advancement of learning, I.v.5, in Bacon , The advancement of learning and New Atlantis, ed. by Johnston A. (Oxford, 1974), 34. On Baglivi's admiration for Bacon see Martin J. , “Sauvages' nosology” (cited in ref. 202 below), 115–18.

Baglivi , The practice of physic (ref. 147), 188. Cf. also p. 22, where Baglivi offered his formal definition of the Medicina prima.

Ibid., 197.

Ibid., 22.

Ibid., 197.

Ibid., 60.

Ibid., 60–61.

See above, at ref. 130.

Baglivi , The practice of physic (ref. 147), 61–66.

For instance, “A good respiration is a good omen, but a bad one is always to be dreaded…. But prognostics taken from the pulse are not so certain…”; and “Such pleuritical patients as were seized with a pain in the inner part of the ear, followed by an imposthume and pus, were all cured, pursuant to my repeated observations in the Italian Hospitals” (ibid., 61). Again, “After the cessation of the pain of inflamed parts (especially in the case of a pleurisy or the inflammation of membranous parts), if the fever still continues, or increases, being attended with a low, intermitting and frequent pulse, cold sweats, etc., 'tis a fatal omen…” (p. 63).

Baglivi recommended bleeding (without considering its site, and so without mentioning the controversy which had raged in Vesalius's day) and expectoration, and argued against purgatives and diaphoretics: ibid., 62, 64–65.

Ibid., 62, 63, 65.

Ibid., 22, quoted above, at ref. 158.

Ibid., 20–21, 114–16, 118, 126–7, 197.

Morgagni G. , De sedibus et causis morborum per anatomen indagatis (Venice, 1761); On the seats and causes of diseases, investigated by anatomy (transl. by Alexander B. , 3 vols, London, 1769).

Baglivi , The practice of physic (ref. 147), 2.

See Lindeboom G. A. , Herman Boerhaave: The man and his work (London, 1968), 274–5, and contrast Morgagni, On the seats and causes of diseases (ref. 169), 613.

True, we have two excellent, complementary recent discussions: Nicolson M. , “Giovanni Battista Morgagni and eighteenth-century physical examination”, in Lawrence C. (ed.), Medical theory, surgical practice (London, 1992), 101–34, and Cunningham A. , “Pathology and the case-history in Morgagni's ‘On the Seats and Causes of Diseases Investigated Through Anatomy’ (1761)”, MedGG, xi (1995), 37–61. But a great deal more remains to be learnt from the 2,242 pages of On the seats and causes of diseases.

On Morgagni see also The clinical consultations of Giambattista Morgagni: The edition of Enrico Benassi (1935), translated and revised by Jarcho S. , with new preface and supplements (Boston, 1984).

Morgagni , On the seats and causes of diseases (ref. 169), ii, 546–80 (Letter 20), 581–643 (Letter 21).

On Morgagni's logic see Jarcho S. , “Morgagni, Vicarius, and the difficulty of clinical diagnosis”, in Stevenson L. G. Multhauf R. P. (eds), Medicine, science and culture: Historical essays in honor of Owsei Temkin (Baltimore, 1968), 87–95; on the anatomical and case-historical dimensions of Morgagni's enterprise see Cunningham , “Pathology and the case-history” (ref. 172).

By explaining the anomaly Morgagni was able to advance a hypothesis as to the source of the pain-in-lying-down (On the seats and causes of diseases, 555), a hypothesis which fed into his larger subsequent discussion (see for instance p. 558).

Ibid., 569–70. Here Morgagni duly noticed that the anomaly he had observed was also of ancient record, in Caelius Aurelianus's Acute diseases (ref. 94).

See above, at ref. 145.

Morgagni , On the seats and causes of diseases, 627.

Ibid., 621–30.

In all probability, Morgagni had grossly exaggerated Baronius's contribution, and had suppressed the writings of many other authors, for in fact this conception went back to the sixteenth century and was well known in the early eighteenth century: See the citations under the entry for “pleuro-pneumonia” in the Oxford English dictionary. Nevertheless this licence on Morgagni's part was justified, for pleurisy and peripneumony were regarded as distinct diseases by Boerhaave, by van Swieten, and by all the leading nosologists, among them Sauvages, Linnaeus, Vogel and Cullen. See van Swieten G. , The commentaries upon the aphorisms of Dr. Herman Boerhaave concerning the knowledge and cure of the several diseases incident to human bodies (transl. anon., 18 vols, London, 1744–73), viii and ix (separate and extended treatments of peripneumony and pleurisy respectively); Cullen W. , Synopsis nosologicae methodicae (Edinburgh, 1769), 30, 33, 103, 105, 171, 260–1.

Garrison remarked: “It is said of him [Boerhaave] that he was the first to establish the site of pleurisy exclusively in the pleura…”: Garrison F. H. , An introduction to the history of medicine (first published 1913; 4th edn, Philadelphia, 1929), 317, giving no reference. I have not identified the origin of this particular claim.

Duffin , To see with a better eye (ref. 6), 145–7, 216–17.

Ibid., 205.

(1) The pain-in-the-side was described as being intensified by inspiration (J. Duffin, personal communication); this had already been identified earlier (see van Swieten , Commentaries (ref. 181), ix, 1). (2) The hard pulse had apparently been dropped as a diagnostic sign; I have not established when this took place. (3) Survivors of chronic pleurisy had retraction of one side of the chest; this was discovered by Laennec himself ( Duffin , To see with a better eye (ref. 6), 161).

Ibid., 158.

Maulitz , “In the clinic” (ref. 6).

Most of what follows rests specifically on Chomel's observations, of which Maulitz gives examples drawn from students' lecture-notes (ibid., 134–5), but the link between pleuritis and phthisis was apparently characteristic of the Paris school at this time (p. 133). The quotations in the next four references are from Chomel, in ibid., 134–5.

“The stitch in one's side [that is] worsened by inspiration and by cough is characteristic of pleurisy.”.

“Phthisical patients from time to time are subject to pleuritic stitches without effusions.” See also the quotation in the next reference.

“Certain cases of pleurisy are accompanied only by a pseudomembranous exudate, in which case there is neither dullness nor egophony.” Conversely, Andral had already argued in the 1820s that (as Duffin puts it) “egophony could exist under false positive circumstances, when there was no effusion at all” ( Duffin , To see with a better eye (ref. 6), 205).

See the quotation in ref. 190 above, and also: “In chronic pleurisy we have often found tubercles in the chest of those who have succumbed.”.

Duffin , To see with a better eye (ref. 6), 158–9.

In the next letter of De sedibus (Letter 22), Morgagni discussed phthisis along with empyema; here he linked “pleuripneumony” (the concept which had now replaced both pleurisy and peripneumony) with empyema, and not with phthisis ( On the seats and causes of diseases (ref. 169), 650, 655; cf. refs 110, 121 above). True, he suggested that some of Valsalva's “peripneumony” cases (which he had discussed in Letter 20) actually “related rather to consumption” (p. 645); but this was as near as he came to linking pleurisy or “pleuripneumony” with consumption. It should also be observed that De sedibus included only a few cases of phthisis, because both Valsalva and (even more so) Morgagni were “cautious” about dissecting the bodies of consumptives, evidently through fear of contagion (pp. 645, 661).

Maulitz , “In the clinic” (ref. 6), 130–1.

Duffin , To see with a better eye (ref. 6), 247.

See above, at ref. 174.

Cf. Jordanova L. , “The social construction of medical knowledge”, Social history of medicine, viii (1995), 361–81, particularly p. 374.

See for instance Porter R. (ed.), Patients and practitioners: Lay perceptions of medicine in pre-industrial society (Cambridge, 1985); Beier L. McC. , Sufferers and healers: The experience of illness in the seventeenth century (London, 1987); Porter R. Porter D. , In sickness and in health (London, 1989); Porter D. Porter R. , Patient's progress: Doctors and doctoring in eighteenth-century England (Oxford, 1989).

For a fine illustration of this point see Nicolson M. , “The metastatic theory of pathogenesis and the professional interests of the eighteenth-century physician”, Medical history, xxxii (1988), 277–300.

Cf. Duffin , To see with a better eye (ref. 6), 302–3.

For two very different accounts see French R. , “Sickness and the soul: Stahl, Hoffman and Sauvages on pathology”, in Cunningham A. French R. (eds), The medical enlightenment of the eighteenth century (Cambridge, 1990), 88–110, and Martin J. , “Sauvages' nosology: Medical enlightenment in Montpellier”, ibid., 111–37. For the most recent word on Sauvages, see Brockliss L. Jones C. , The medical world of early-modern France (Oxford, 1997), 427–9, p. 435 and passim.

This crucial issue has been raised by French , “Sickness and the soul” (ref. 202), who stresses the differences; but Martin, in “Sauvages' nosology” (ref. 202), can be read as emphasizing the continuities between the two.

For an overview see Bynum W. F. , “Nosology”, in Bynum Porter (eds), Companion encyclopedia of the history of medicine (ref. 6), i, 335–56.

Foucault , Birth of the clinic (ref. 43), chap. 1 and passim; Porter R. , “The eighteenth century” in Conrad L. I. , The Western medical tradition (Cambridge, 1995), 371–475, pp. 409–10. See also Maulitz , “In the clinic” (ref. 6), passim, and Duffin , To see with a better eye (ref. 6), 68–69, 251, who both find that nosology remained very much alive in the Paris clinic.

Dr Shyamsunder Rao Chepur assures me (personal communication, 1998) that there are in the Ayurvedic tradition at least two standard diagnostic categories which correspond to, or overlap with, pleurisy: (1) Parshuka roga (“disease of the sides”); and (2) Utpullika (a “respiratory disorder” associated with “painful swelling in the right hypochondrium and intercostal space”). But I have yet to discover just how those categories developed historically within that tradition.