The medicine between the lines

Ketil Slagstad About the author

Borders, scribbles, yellow highlighting, footnotes, tables of contents, fonts, illustrations, comments fields and design are also medicine.

Petrus de Abano (1257–1316) was an Italian philosopher and professor of medicine. In his book De venenis, which is based on Arabic sources and deals with matters such as poisons, the listed medical conditions and medicinal plants are meticulously arranged in columns, with associated comments and annotations. Robert MacLean argues that these texts were written for posterity, in the panicked ambition of the time to preserve ‘everything’. Therefore, the added notes were also categorised and arranged with initial capitals marked in red to arrange the information for later generations. Illustration: Petri de Abano. De venenis. Rome: Georgius Sachsel and Bartholomaeus Golsch, approx. 1475. Reprinted with permission from the University of Glasgow Library, Special Collections.

Reading an old book full of underscoring and scribbles can be quite irritating. On the other hand, borders, notes in the margin, drawings, pictures and yellow highlighting may provide a kind of access to history, at least medical history, that has hitherto gone unheeded. This assertion is the starting point for the anthology Medical Paratexts from Medieval to Modern, about a relatively new area of research, namely medical paratext or non-textual medical text.

The book starts with the editors Hannah C. Tweed and Diane G. Scott presenting the mysterious case of Mary Toft, who in 1726 gave birth to nine rabbits, witnessed by a British surgeon. The case was widely reported in the press and became legendary, because it also came to feature in skits and ballads. After Toft had repeatedly given birth to rabbits in the presence of witnesses, she was brought to London for a thorough examination by surgeons, medical practitioners and male midwives. There it was revealed that her husband had provided her with dead rabbits that she had used during her ‘births’. After she had been threatened with a forced Caesarean section, she confessed to the scam.

What role does the story of Mary Toft play in a book about medical paratext? The discovery caused a flood of contributions from doctors, surgeons and midwives, and the editors argue that with all the text produced, the debate can be better understood if we analyse not only the texts themselves, but also their paratext. Paratext is varyingly defined and delimited, and in the widest sense it includes everything that surrounds the main text and itself communicates information and meaning (‘para’ means ‘beside’ in Greek). The paratext includes the peritext – such as illustrations, covers, colophon pages, annotations in the margins, headings, footnotes and endnotes – i.e. elements that are linked to the main text but not themselves included in it. The paratext also includes the epitext, i.e. text produced outside the original text, such as literature reviews, responses to articles, correspondence, public debates and press releases. The epitext reveals to us the social, political and cultural factors that shaped the production of the text.

One key point highlighted by the editors is that paratext always mediates between the author, publisher and reader: the paratext is relational. In Toft’s case, such analysis of the paratext demonstrates how the female body became the object of a struggle in which many saw the need to defend their knowledge and their profession, not least because so many professionals had been led down the garden path. The analysis also shows how new opportunities for publication in the 18th century were utilised by an increasingly self-confident medical profession.

Medical-erotic knowledge

In addition to the introduction, the book consists of nine chapters, and most of the authors have a background in history, literature or linguistics. It spans a long period and a broad range of topics: from the 14th to the 21st century, and from illustrated 17th century flyers advertising quack surgery to the overlooked diary notes of First World War nurses. In turn, this last example testifies to writers who self-confidently juggle various roles – those of feminist, professional, eyewitness and historian. Such a breadth of perspective lends weight to the argument about the importance of paratext for historiography. On the other hand, unless the examples are perceived as related, there is a risk that the argument might collapse. The editors have been able to strike a good balance between these concerns.

The interest of this reader was piqued by four of the chapters in particular. Harry Newman convincingly demonstrates how printed sources are not only passive objects, but actors in the age in which they were written, as well as in subsequent generations. He shows this by examining the anatomy textbook Mikrokosmographia: A Description of the Body of Man, published in England in 1615. The inscriptions in the book indicate to Newman that the books were read not only by the learned, but also by common folk, and that they were owned and read by women and men alike. Illustrations of the female anatomy in particular gave rise to debate in medical circles, and were found to be indecent. In subsequent editions, the little line on the vulva visualising the pudendal cleft was removed. According to Newman, this caused it to be conspicuous by its absence (Figure 1). Precisely this removal/censoring/retouching of the improper helped fetishise the forbidden. An analysis of the book’s paratext of both a warning (‘the following may be felt as offensive’) and apologetic nature (‘why is it important to publish this?’) demonstrates a medical-erotic knowledge and the fetishist function of the medical paratexts.

Figure 1 The figure shows a female torso in two different editions of the book Mikrokosmographia: A Description of the Body of Man by Helkiah Crooke. To the left is the original edition from 1615, to the right the 1631 edition where the pudendal cleft has been retouched away. In other versions, readers have redrawn it. On the illustration to the right, a reader has added a pen drawing of the head. The censorship, de-censorship and personalisation of the torso exemplify how the paratext reveals a historic relationship between the author, publisher and reader. Left illustration: Helkiah Crooke. Mikrokosmographia, 1615. Reel position: STC/1409:01. Henry E. Huntington Library and Art Gallery. Reprinted with permission from ProQuest Early English Books Online (, do not reproduce without permission. Right illustration: Photo by Robert MacLean. Reprinted with permission from the University of Glasgow Library, Special Collections.

Twins touching: cultural discomfort

In another chapter, Louise Powell examines the interaction between text and pictures in two English midwifery books from the 17th century. In the obstetrics of the time, touching was seen as a key aid to diagnostics. By palpating, the midwife could identify twin pregnancies that revealed themselves through a sagittal cleft across the mother’s abdomen. In this way, conjoined twins, which were considered ‘monstrous pregnancies’, could be distinguished from regular twins. This premise, however, rested on the assumption that there was interaction only between the twin and the mother (and between conjoined twins), but not between regular twins themselves. In this way, the practice of touching as a diagnostic tool could be effortlessly defended in the textbooks, but Powell highlights how the illustrations simultaneously told a different and more complex story. Here, the twins hold on to each other’s arms and legs (Figure 2). The interaction between the text and the paratext communicates a nervous duality: on the one hand, twins do not touch each other and can therefore be diagnosed from the outside (text), on the other hand they touch each other and thereby communicate that they are united by a special bond (illustrations/paratext). Powell finds the justification for the double message in textbooks in the widespread contemporary practice of separating twins from each other after birth. Since it was assumed that the mother would not have enough milk to feed both, the mother kept only one; the other was given to a wet nurse. The interaction between the text and image communicates that this practice entailed a certain cultural discomfort, although the separation practice could be defended: yes, twins do have a special bond, but it is sufficiently strong to withstand the separation after birth.

Figure 2 Twins in utero in Thomas Chamberlayne’s book for midwives, The Compleat Midwife’s Practice Enlarged from 1656. While the text maintained that the twins did not touch each other, the illustrations showed twins that held on to each other’s arms and legs. This duality conveyed a contemporary disquiet about the practice of separating twins after birth. Photo: Thomas Chamberlayne. The Compleat Midwife’s Practice Enlarged, London: J.P. Fellow of the College of Physicians, 1697. Freely available at the U.S. National Library of Medicine. Digital Collections.

Paratext and the credibility of medicine

Laura Mainwaring analyses what packaging and marketing of pharmaceutical products can tell us about the influence of paratext on the drug market of pharmaceutical enterprises, pharmacies and consumers in the transition from the 19th to the 20 century. Patented drugs were some of the first products to be distributed nationwide, as early as the 17th century, and drugs have therefore played a key role in the history of advertising. A significant formalisation of brands resulted from the British Trade Marks Registration Act of 1875, which defined a brand as a visual characteristic or logotype. As a result, packaging and advertising of drugs were marked with a typographical text or a logotype that clearly signalled a particular brand name. Mainwaring reads the products and the paratext of the advertising as an expression of a need to demonstrate authenticity and credibility in an increasingly depersonalised, capitalist market where the direct relationship between the manufacturer and consumer was broken, such as through the pharmacies (Figure 3). Mainwaring claims that the paratext thereby demonstrates that manufacturers had greater confidence in the consumers’ ability to assess drugs than has been previously assumed. The materiality of the paratext (e.g. drug bottles, brand stamps, declarations of precautions, packaging and advertising) therefore tells two stories. First, it reveals how drugs have been communicated to the population through history. Second, it demonstrates how drugs had been given new functions at the turn of the 20th century and increasingly addressed the consumer directly. Therefore, the paratext points ahead to a century in which drugs and medical science would come to play such a dominant role in social development and people’s lives.

Figure 3 The Chemist and Druggist was a magazine aimed at sales of drugs to pharmacies. The paratext in this Wellcome Brand advert for the anaesthetic chloroform communicated a number of messages: a self-confident, advancing pharmaceutical industry (monumental industrial buildings in the neo-classicist style), a paranoia about forgeries (life-sized bottle, packaging and seal) and a brand name (Wellcome Brand, Trade Mark). Photo: Wellcome Collection.

In the final chapter, Robert MacLean takes us on a flying visit through annotations, scribbles and indexations in the margins of textbooks – so-called marginalia – in a selection of medical incunabula (books printed using old techniques prior to 1500) and printed sources on syphilis dating from the 16th to the 18th century. One of MacLean’s points is that the cataloguing and archiving of such metadata-rich sources are extremely time-consuming and costly. Only a fraction of the early printed sources has been catalogued at a sufficiently detailed level, and this represents in turn a considerable limitation on research about medical marginalia.

History that comes into being

Seen as a whole, the book expands our understanding of medicine as a paper technology. Not only do we see how medicine largely has been about writing for contemporary and future audiences, but also how the text of a particular era has continued to have an effect in posterity. The book provides a valid argument for the assertion that if we ascribe the same weight to the paratext as we do to the text itself – and include illustrations, fonts, tables of contents and footnotes, publishing formats, drawings and notes in the margins, reception, correspondence and letters – this may perhaps open our eyes to new perspectives on the dialogical, active and historic functions of the texts.

The book in question. Hannah C. Tweed, Diane G. Scott, eds. Medical paratexts from medieval to modern. Dissecting the page. London: Palgrave Macmillan, 2018.

Paratext features not only in historic texts, however. The Journal of the Norwegian Medical Association, in which this article is published, is full of paratext that future historians (perhaps) might analyse to understand medicine in the early years of the 21st century: we invite artists to illustrate the cover, thus to provide a different perspective on original research, the comments field lends new life online to articles printed on paper, and new types of article genres help us organise knowledge.

One of the historian’s most powerful and important tools is contextualisation, meaning to place a text, a piece of archive material or an object in its contemporary context and interpret it according to the premises of its own time. Thereby, other texts, other discourses, social, political and cultural aspects are included to enhance our understanding of the setting in which the text was written. However, contextualisation has also been criticised as an ‘easy’ method of explaining historic events that simply have not been studied in sufficient detail (1). History turns into a ‘black box’, where the past just is, separated and with no reference to the present, and where the job of the historian is simply to find out ‘how things really were’.

History, though, is also something that we do; history is a process of becoming (2). Texts are not merely passive representations of bygone times. They acted at the time when they were written, they were used by later generations and continue to have an effect in the present, in our understanding of the past, the present and the future. This is precisely the point that I feel emerges clearly from this small but beautiful anthology, where the traces of time are given shape. Context is Latin for ‘to weave together’. Texts travel across time and weave it together. If we direct our gaze towards the paratext, the time and situation in which the text appeared and functioned seem a little less passive and more alive. As a result, we can better understand the medicine of the past – and perhaps even gain some new perspectives on our own practice.

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