Introdução: O Curso Experimental de Medicina (CEM) vigorado de 1968 a 1974 na Faculdade de Medicina da Universidade de São Paulo (FMUSP), foi uma estrutura curricular de ensino divergente dos padrões da época. O CEM consistia em um modelo integrado de ensino por blocos, sendo considerada uma forma mais atualizada para a formação médica. Essa nova concepção de ensino causou forte oposição entre docentes e apoiadores do curso tradicional. A reunificação dos cursos tradicional e experimental em 1974 neutralizou a nova proposta de ensino, porém, mantiveram-se, até os dias de hoje, reflexos de sua existência. Objetivo: Estudar a constituição do CEM, bem como seus elementos construtores por meio de narrativas dos seus protagonistas, apresentar critérios de comparabilidade com o curso denominado tradicional da FMUSP e verificar junto aos ex-residentes de Anestesiologia do período-vigente, o impacto dos referidos cursos na formação dos mesmos. Metodologia: Foram adotadas duas técnicas para a investigação: o levantamento de documentos institucionais oficiais e entrevistas semiestruturadas com resposta aberta envolvendo docentes e discentes pertencentes ao CEM e ao curso tradicional. Resultados: Onze docentes foram entrevistados, colaboradores de ambos os modelos, 12 ex-discentes do CEM, 12 ex-discentes do curso tradicional e 7 ex-residentes de Anestesiologia, configurados em 3 participantes do curso experimental e 4 do tradicional. O principal aspecto relatado foi a integração entre as disciplinas. Entre os discentes, o enfoque dado aos aspectos do CEM foram a sólida formação teórica em Ciências Básicas e o bom desempenho como médico generalista. Relata-se um revisitar frequente do conteúdo, que facilitava o aprendizado, uma maior aproximação discente-docente, proporcionando segurança na escolha da especialidade, com maior predileção dos alunos pelas especialidades na qual os docentes estavam mais próximos. Para os docentes, as reuniões frequentes com outros professores proporcionavam discussões norteadoras sobre pontos principais a serem abordados em diferentes disciplinas. Os alunos do curso tradicional referenciam-se a este como um modelo que não privilegiava um processo formativo amplo, compartimentando-se o conteúdo de modo a não possibilitar um repertório interativo entre discentes e docentes. Os apontamentos realizados pelos alunos do curso tradicional coincidiram com as reflexões dos ex-residentes em Anestesiologia, que elencaram lacunas no currículo da graduação médica. Conclusão: O CEM determinou grandes mudanças de paradigma quanto ao ensino médico, sendo a formação integrada entre disciplinas e a aproximação entre docente-discente notados como condições distintas e fundamentais entre os currículos / Introduction: The Medical Experimental Course (MEC), which lasted from 1968 to 1974 at the Faculty of Medicine of the University of São Paulo (FMUSP), was a curricular method that diverged from the standard curriculum present at that period. The standard curriculum could be described as classes based on expositive lectures during the years prior to internship, while the MEC consisted of an integrated model of block-based. This new conception of teaching caused strong opposition between teachers and supporters of the traditional course. The reunification of the traditional and experimental courses occurred in 1974 and extinguished the new teaching proposal, but remains of its existence persists today. Objective: To study the formation of the MEC, as well as its constructive elements through narratives of its protagonists, to present comparison criteria between the MEC and the traditional course and to check with the former residents of anesthesiology the impact of the MEC. Methods: Two data analysis techniques were adopted: the collection of official documents and the production of semi-structured interviews with open response involving teachers and students of the MEC and the traditional course. Results: Eleven teachers, collaborators of both models, 12 former students of CEM, 12 former students of the traditional course and 7 former residents of Anesthesiology. The main aspect reported by the MEC students and teachers was the integration between disciplines. Among the students, the focus given to the MEC aspects was the solid theoretical background in Basic Sciences and the good performance as general practitioner. It is also reported that there was constant revisiting of the content, which facilitated the learning and a greater student-teacher approach, providing an easier choice of the specialty. The CEM students also had a greater preference for the specialties in which the teachers were closer. For teachers, frequent meetings with other teachers provided guiding discussions on key points to be addressed in different disciplines. The students of the traditional course refer to this as a model that did not favor a broad formative process, compartmentalizing the content so as not to allow an interactive repertoire between students and teachers. The notes made by the students of the traditional course coincided with the reflections of the former residents in Anesthesiology, which listed gaps in the medical graduation curriculum of FMUSP. Conclusion: The CEM determined great changes regarding medical education, with integrated training between disciplines and the approximation between teacher-student noted as distinct and fundamental conditions between the curricula in present at that time

Cette thèse examine l’œuvre poétique de Rimbaud et de Laforgue du point de vue de la catégorie de « folie ». La notion de folie a très souvent été mobilisée dans la première réception de tout un pan de la poésie écrite dans le dernier tiers du XIXe siècle, pour étiqueter des textes considérés comme illisibles. À tel point qu’avec ses corollaires d’époques (manie, névrose, dégénérescence, hystérie), elle est devenue un véritable paradigme de lecture du texte poétique. La folie est envisagée ici non pas seulement dans sa définition médicale, mais aussi comme objet hybride, construit par une multiplicité de discours et de pratiques. On commence par une archéologie de ce discours médicalisant qui pathologise la poésie, pour montrer ensuite que la « folie » constitue bien une catégorie valide pour l’appréhension de la poésie rimbaldienne et laforguienne, mais qu’elle nécessite pour cela une théorisation nouvelle, indépendante de toute considération biographique ou psychologique. Part essentielle de l’écriture, la folie chez Laforgue, Rimbaud et leurs contemporains n’est plus la folie romantique – qui s’articulait aux catégories du grotesque ou du magisme inspiré. La folie poétique se fait méthode, « raisonné dérèglement » selon la formule paradoxale de Rimbaud, et traverse, en tant qu’expérience-limite, tout le trajet lyrique. En même temps, elle devient immanente aux corps, et au corps du texte. La folie romantique s’est immanentisée et textualisée. Poétique de la folie désigne ici un fait littéral, la manière dont le texte se trouve altéré par la folie, et réciproquement la manière dont en tant que poème ce même texte reconfigure la langue et la lecture, devenant par là un autre nom de la « folie » comme intempestivité, invention de catégories nouvelles, illisible devenant lisible. La folie ne désigne plus alors une pathologie, mais la force d’évènement de l’écriture même. Chez Laforgue et Rimbaud, cette dimension de bouleversement se déploie particulièrement dans trois champs : comme expérience radicale, la folie opère une altération et une aliénation du sujet ; comme effet rhétorique, elle entraîne un trouble généralisé de la syntaxe et du sens ; en tant que contre-discours et résistance à l’ordre établi (hystérie, idiotie, fureur) enfin, elle possède en elle-même une dimension politique, par laquelle elle s’articule à l’histoire comme événementialité. / This dissertation looks at the poetic works of Rimbaud and Laforgue from the point of view of “madness”. The category served as a label that was often applied by contemporary readers, including medics, to a corpus of poetry they considered to be illegible. Madness and its then quasi synonyms – mania, neurosis, degeneracy or hysteria – thus became no less than a general paradigm for reading poetry. We conceive of madness here not as a mere medical concept, but as a hybrid object, one that is constructed through multiple discourses and practices. The thesis first takes an archaeological look at this medicalisation of the reception of poetry. It then moves on to show that the category of “madness” can indeed be valid when it comes to understanding the lyric of Rimbaud and Laforgue, but needs new theorisation as a concept. Madness should no longer be considered as a biographical or even psychological category, but as pertaining to the text itself. A crucial part of the act of writing both for Rimbaud and for Laforgue, madness at the Fin de siècle had moved away from its definition in French romanticism, which saw it primarily as akin to the category of the grotesque or that of transcendent inspiration. Madness became a paradoxical method for poetry, according to the rimbaudian phrase “raisonné dérèglement” (“reasoned derangement”). As a limit-experience, madness proves to be at the core of a new poetic practice, while becoming immanent to the bodies as well as to the body of the text. Talking about a “poetics of madness,” we therefore conceive of madness as being primarily textual or literal. The poetic text is altered and displaced by madness, and conversely the text itself qua poem transforms the language it is written in and the categories of reading that are applied to it. In that sense, the text is necessarily mad in its essential untimeliness, since it invents the categories in which it can become legible. Madness thus no longer refers to a form of pathology, but rather designates poetic writing itself as a force and an event. Such a disruptive force is studied more particularly in three domains. As a radical experience, madness alters and literally alienates the subject. As a rhetorical effect, it brings about a major trouble within syntax and meaning. As a counter-discourse, finally, and a resistance to social order (in the cases of hysteria, idiocy, or fury), madness has an immediate political dimension to it, which connects it to history qua eventiality.

L’opinion moderne a souvent laissé juger la médecine scientifique comme étant la seule véritable médecine à même de guérir toute sorte de maux, tout en n’accordant pas suffisamment d’intérêt ou en mettant à une échelle nettement inférieure d’autres formes de pratiques médicales telles que la médecine magico-religieuse et/ou divine dans le monde grec ; pratiques qui se voient dénuer de toute efficacité au profit de la médecine dite scientifique. À travers notre thèse, nous nous proposerons de démontrer que ces autres formes de thérapie estimées comme secondaires méritent d’être à nouveau considérées, au moins de manière relative, avec une approche nouvelle. Grâce à l'archéologie, l'on peut attester que la Grèce du siècle de Périclès a connu des cultes de guérison impliquant des démarches religieuses préliminaires ainsi que des rites d'actions de grâce. Souvent pour multiplier ses chances de guérison, le malade pouvait à la fois faire appel aussi bien aux expériences humaines qu'à celles irrationnelles ; et le plus souvent le recours aux pratiques irrationnelles faisait la différence : l'épiphanie ou l'intervention du dieu au cours d'un rêve suffisait à guérir le malade. Ainsi naquit l'incubation au cœur de l'interrogation médicale salutaire du patient. Dans ce processus de guérison, le sommeil des pèlerins ne s'apparente en rien au sommeil ordinaire d'une nuit quelconque, et le rêve y a par conséquent une place assez particulière, un rôle crucial : il ne s'agit pas de rêves ordinaires, mais ce sont des rêves contrôlés, codifiés et manipulés par des spécialistes dans le cadre d'un usage précis, le conseil ou une thérapie. La pratique de l'incubation devient ainsi une nécessité voire une opération ultime et indispensable pour préserver le bien le plus précieux et impérieux de l'homme, la santé. La guérison peut alors être garantie partiellement ou totalement par le rituel incubatoire, entre autres pratiques. Cette pratique revêt ainsi l'apparence d'un véritable rituel d'initiation, elle suppose la reconnaissance de l'omnipotence du dieu sauveur (Asclépios très souvent accompagné de sa fille Hygie, ou Amphiaraos d'Oropos ou Trophonios de Lébadée) et oblige le patient à un renouveau, à une purification dans le processus de guérison. Elle est vécue comme une expérience de contact avec le divin. À l'issue de cette phase incubatoire, les consultants exaucés se voyaient dans l'obligation d'apporter en contrepartie des offrandes qui constituent aujourd'hui des témoins insignes : des inscriptions votives, stèles, des ex-voto anatomiques, des statues sculptées à l'effigie du dieu, des pinakes, et des reliefs votifs, pour en faire profiter à d'autres patients atteints du même mal. Ce sont tous ces vestiges, de la Sicile à l'Asie mineure, qui couvrent une période allant du début de l’époque classique (Ve siècle av. J.-C.) jusqu’à la fin du IIIe siècle de notre ère, que vous verrez regrouper dans notre corpus, dans une perspective d'édition. / Dating between the second half of the fourth century and the third century after Christ, the steles which we study for publishing, are votive inscriptions engraved generally in Dorian dialect under the initiative of the priests and the doctors of the sanctuaries of Asclepius, Amphiaraos or Trophonios. These epigraphic documents testify of miraculous healing realized by these gods towards faithful consultants in the sanctuaries which are dedicated at Epidauros, Athens, Pireus, Lebena, Cos, Pergamon, Corinth, Oropos, Livadia... In the hope of a cure or advice, the faithful consultants are asked to spend at night in a specific room for the ritual of the incubation, after preliminary rites (ritual bath, sacrifice…). During their sleep, the god or even one of his auxiliaries, the snake or the dog, appears to them in a dream: and this epiphany or intervention is enough to cure the patient, or to satisfy the needs of the consultant. The following day, the cured patients are supposed, by way of gratitude, either to offer to the god the effigy of their sick organ (the anatomical ex-voto) or to make engrave generally on wooden tablets the narrative of their cure, which they fix then to the wall of the temple. But for the sake of preserving these stories for posterity, the staff of the temple decided to transcribe on large steles in limestone or marble, proposing us real catalogues of miraculous healings. These documents are nevertheless very important in the field of the ancient Greek medicine: a medicine which offers however a curious mixture of mantic knowledge and rational knowledge in the process of cure. While observing the tensions between the traditional faith in the divine causality and the Hippocratic rationalism, we make a comparative study of the medical words used on our steles with the glossary of the contemporary medical literature spotted in the whole of the literary medical texts. And we can notice many diseases and the means of treatments (dietetic, surgery, chiropractic, pharmacopoeia, herbal medicine…), but also the popular beliefs about dream et disease in Ancient Greece.

Building on recent scholarship in the history of art which has started to reappraise the meaning of grotesque and scatological motifs, this thesis examines how digestion was conceived of as a model of creation, and how this was translated visually. Renaissance creativity was increasingly modelled on a series of natural processes like digestion, following a trend in favour of Aristotelian psychology. However, it has been largely overlooked in comparison to the bleeding, the pneumatic, and especially the procreative natural models, which have been extensively studied. The central argument of this thesis is that digestion constituted an alternative-albeit less 'decorous'-model of creation, denoting the intervention of a more 'earthbound' ingenium. I argue that this model was used by certain classes of artists as an acknowledgement of a strong engagement with materials and of the labour of a round-the-clock imagination. Goldsmithing and printmaking are artistic professions whereby the artistic process was often considered as an act of 'soiling' oneself, both in the sense of the body and the phantasia. This thesis focuses on a period spanning c. 1530 to 1675, from Rabelais' works to the facetious printer Jacques Lagniet. It mines a corpus of little-studied textual and visual sources from the north of the Alps, examining a continuity between France and the German lands: geographical areas which both had an especially pronounced 'culture of excretion'. From a broader perspective, this research responds to a widespread scholarly call for more attention to the organic soul and the lower body, nuancing the alleged hegemony of the brain and the higher senses throughout history. It seeks to modify the perception of early modern artists and viewers as cerebral intellectuals, presenting them as individuals who also 'thought with their guts'.

Made available in DSpace on 2016-04-28T14:16:14Z (GMT). No. of bitstreams: 1 Luciana Costa Lima Thomaz.pdf: 4629609 bytes, checksum: e0c75ddd8fe34d9f36e7124278be8c2e (MD5) Previous issue date: 2011-12-09 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The traditional approach to medicine in the West was grounded on the classification of the endless human diversity in classes (complexions). With the rise of modern science, the focus of medicine gradually shifted to the physical and chemical processes proper to living matter. Consequently, the practice of medicine became dependent on the diagnosis of clinical entities, which were classified according to their etiopathogenic mechanisms, in turn dependent of biomolecular phenomena. Despite this mainstream direction, countless typological classifications burst out in the first decades of the 20th century in a wide range of contexts anthropology, criminology, psychology, education, etc. including medicine. To understand this phenomenon, this study focused on biotypological theories grounded on the assertion that there is an intrinsic relationship between human types and embryological layers, the work by Marcel Martiny (1897-1982) in particular. Analysis carried out within three overlapping spheres addressing sociohistorical, epistemological and historiographical aspects allowed identifying strong eugenic element in biotypological theory as formulated in the first half of the 20th century within the context known as medical Holism . This was also the background for Martiny, whose experimental work is restricted to anthropometric measurements that then were related with physiological and biomolecular phenomena exclusively by way of analogy. After World War I biotypological theory was depurated from all eugenic elements, whereas its lack of any empirical foundation was neglected and despite its contradictions, it is discussed even in our own days as if it were sound science / A medicina tradicionalmente vigente no Ocidente se baseava na classificação da heterogeneidade humana em diversos tipologias (compleições). Com a formulação da ciência moderna, gradualmente, a base da medicina passou a focar os fenômenos físicos e químicos que ocorrem na matéria viva. Assim, a prática clínica passa a depender do diagnóstico de entidades nosológicas, classificadas segundo seu mecanismo etiopatogênico, por sua vez, dependente de mecanismos biomoleculares. No entanto, nas primeiras décadas do século XX acontece uma explosão de classificações tipológicas numa variedade de contextos antropologia, criminologia, psicologia, pedagogia, etc. incluindo a medicina. Para abordar esse fenômeno, focou-se as teorias que afirmavam uma relação intrínseca entre as tipologias humanas e os folhetos embrionários, em particular, a obra de Marcel Martiny (1897- 1982). A análise realizada em três esferas superpostas, levando em conta aspectos histórico-sociais, epistemológicos e historiográficos, permitiu identificar fortes componentes eugenistas nas biotipologias desenvolvidas na primeira metade do séculos XX, dentro do chamado holismo médico . Esse é também o pano de fundo do trabalho de Martiny, que utiliza como método, basicamente, medições antropométricas, cuja vinculação aos fenômenos fisiológicos e biomoleculares é realizada de maneira puramente analógica. Depois da Segunda Guerra Mundial, a teoria das biotipologias foi depurada de seus elementos eugenistas, sua falta de fundamentação empírica foi omitida e, apesar de todas suas contradições, continua a ser apresentada como ciência provada em diversos contextos, especialmente, nas abordagens médicas holistas

Depuis l’exploration naissante de l’économie endocrine du masculin jusqu’aux opérations de revitalisation pratiquées dans les années 1920 et 1930, cette thèse montre de quelle manière diverses opérations génitales, dont la vasectomie, participent des stratégies médicales de construction du masculin. En parallèle, la stérilisation masculine volontaire est explorée dans le cadre de projets eugénistes à partir d’une campagne pour la légalisation de la stérilisation en Grande-Bretagne, de débats au sein de la Ligue mondiale pour la réforme sexuelle et du mouvement néo-malthusien français. L’évolution des normes de masculinité et de paternité est enfin questionnée par le recours à la vasectomie comme moyen contraceptif de convenance. L’organisation de vasectomies clandestines, la répression et la réprobation sociale qu’elles suscitent interrogent la disposition de soi du côté des hommes et le rôle normatif de! la procréation. Le caractère polysémique des stérilisations permet ainsi d’explorer globalement les reconfigurations de la masculinité à une échelle transnationale. / From the nascent exploration of the endocrine system of the male to the revitalization operations performed in the 1920s and 1930s, this thesis shows how various genital operations, including vasectomy, contribute to medical strategies for the construction of masculinity. In parallel, voluntary male sterilization is explored in the context of eugenicist projects on the basis of a campaign for legalizing sterilization in Great Britain, the debates within the World League for Sexual Reform and the french neo-malthusian movement. The evolution of the norms of masculinity and paternity is finally questioned by the use of vasectomy as a convenient contraceptive method. The organization of clandestine vasectomies, the repression and social disapproval they generate question men's self-determination and the normative role of procreation. The polysemous nature of sterilizations thus makes possible the overall exploration of the reconfigurations of masculinit! y on a transnational scale.

Utilizando como fuente los libros de defunción del registro civil de Cartagena, se ha extraido una muestra aleatoria de 4040 registros (el 2'5% de todas las defunciones del período). De cada caso se han registrado los datos sociodemográficos (sexo, domicilio, edad, profesión...) que han sido puestos en relación con la causa de defunción. Para alcanzar este objetivo ha sido necesario elaborar un tesauro que permitiera una correcta ordenación y comprensión de las expresiones diagnósticas que informan sobre la causa de muerte. La tasa de mortalidad media fue del 27'5 por mil, con un alto peso de la mortalidad infantil (el 43% de las defunciones se dan en menores de 8 años), infecciosa (33'7%) y respiratoria (22'4%), si bien a lo largo del período se comprueba un desplazamiento hacia edades avanzadas y causas relacionadas con "senilidad" y accidentes vasculares; entre las causas específicas sobresale la tuberculosis (10% de las defunciones), y por su importancia relativa, el paludismo. Con el método de Louis Henry se comprueba una estacionalidad de máximos invernales y mínimos estivales. El método de Dupaquier ha permitido identificar 10 crisis de mortalidad, algunas ya documentadas con anterioridad, como la causada en 1918 y 1919 por la gripe, y en 1885 por el cólera. Esta última se prolonga con dos nuevas crisis en 1887 y 1888 Y viene precedida por una anterior en 1877; otras han sido identificadas y estudiadas en 1897, 1906, 1910 y 1928. / A random sample of 4,040 records (2.5% of all deaths in the period) was obtained from the Death Record at the Register Office in Cartagena (Murcia, Spain). Social and demographic data (sex, address, age, profession, etc) were obtained from each case and related to death cause. In order to reach this objective it was necessary to elaborate a thesaurus that allowed a correct arrangement and understanding of diagnosis terms informing on death cause. Rate of mortality was 27.5 by thousands, with a high percentage of children mortality (43% of deaths occurred below 8 years of age), infectious causes (33.7%) and respiratory diseases (22.4%). A displacement of mortality to middle aged and elderly and to causes related to senility and vascular illnesses was verified throughout the period. Tuberculosis (10% of deaths) and malaria excelled among specific causes of death. Louis Henry's method verifies the maximum rate of mortality in winter and the minimum in summer. The method of Dupaquier allowed us to identify 10 mortality crises, some previously documented -like those in 1918 and 119 by influenza and also in 1885 by cholera. The latter emerged with two new crises in 1887 and 1888, which was preceded by another in 1877. Finally, others have been identified and studied in 1897, 1906, 1910 and 1928.

The Amphetamine Years is a history of psychostimulant drugs and their clinical applications in post-World War II American medicine. Comprising such well-known substances as the amphetamines (Benzedrine, Dexedrine), methylphenidate (Ritalin), and phenmetrazine (Preludin), this class of pharmaceuticals has been among the most widely consumed in the past half-century. Their therapeutic uses for a variety of indications such as depression, obesity, and attention-deficit/hyperactivity disorder (ADHD) in children, not to mention their relevance for a number of different medical specialties, reveals that psychostimulants have occupied an important, if underappreciated role in the practice of modern medicine. In this dissertation, I illuminate the various ways in which physicians, particularly psychiatrists, put these drugs to work in clinical practice. In short, I contend that physicians exploited the wide range of physiological and psychological effects of psychostimulants and made a place for them in different therapeutic settings, even ones characterized by competing views and theories about the workings of the human body and mind. My dissertation is distinguished by two prominent themes. First, I emphasize the clinician perspective as a vehicle for understanding the history of the psychostimulants, as well as related developments in psychiatry, pharmacotherapy, and the political economy of drugs, in the second half of the twentieth century. Scholars such Nicolas Rasmussen, David Courtwright, and Ilina Singh have elucidated the history of psychostimulants by emphasizing how pharmaceutical companies positioned their products in the medical marketplace. My dissertation takes a different, yet complimentary approach by studying clinicians, themselves, to further historical comprehension of the place of these pharmaceuticals within postwar medicine, society, and culture. Second, I advance the concept of "therapeutic versatility" to explain their historical trajectories. The complex set of psychological and physical effects these drugs produced made them ideal for a diverse range of therapeutic applications, which explains why they were embraced by many different medical specialties, why they were marketed by manufacturers for a variety of indications, and why they have enjoyed an enduring therapeutic lifespan, in spite of increasing efforts since the mid-1960s to regulate their availability and control their consumption. In addition to these two overarching themes, I advance five specific arguments in my dissertation. First, I contend that pharmaceutical markets were simultaneously created by the drug industry and clinicians. Pharmaceutical firms' efforts to develop markets for their products have been well documented by historians, but in my dissertation, I underscore the role also played by clinicians in discerning drugs' applications. Second, I argue that twentieth-century psychiatry's conception of illness and therapeutics may not be served best by strictly dividing its history along lines of institutional and outpatient treatment. Third, I demonstrate how the use of psychostimulants by analytically oriented psychiatrists during the 1950s complicates historical notions of paradigm shift from a psychodynamic to biological orientation. Psychotherapy and psychopharmacology were not competing paradigms; in practice, doctors often employed both. Fourth, I assert that an appreciation of psychiatrists' empirical and eclectic approaches to the use of drugs is necessary to comprehend the rise of psychiatric pharmacotherapy in the postwar era. Finally, I contend that in order to understand the relationship between medical applications of psychostimulants and their extramedical consumption, it is necessary to conceive of a plurality of distinct "amphetamine cultures," each characterized by a unique set of relationships between physician-prescribers, patient-consumers, pharmaceutical firms, and political authorities.

This thesis explores some aspects of the cultural history of the railway during the latter half of the nineteenth century and the beginning of the twentieth. It argues that the railway was of central importance in creating and shaping Victorian attitudes to the machine and to mechanized civilization in a world increasingly dominated by large scale-technologies. In particular, it explores the significance of negative responses to the railway - fear, anxiety, nervousness, alarm, revulsion - in influencing a range of social, cultural and medical responses to the perceived degenerative threat of technological civilization. The four chapters of the thesis are organized so as to provide a progressive tightening of focus on particular aspects of the railway's significance in this context. The first, most wide-ranging, chapter explores the ways in which the Victorian railway was perceived as both an icon of progress and civilization and as a disruptive, threatening, destructive force. In particular, it seeks to establish the deep-rooted, enduring and influential nature of the fear and anxiety which the railway provoked. The second chapter is concerned with the railway journey as an experience, relating the ambivalence with which the railway was viewed to the journey as a sensory, physical and mental experience. The third chapter focuses on the accident as the most dramatic instance of the dangers of the railway, and relates its significance in contemporary culture to the wider context of the fears provoked by increasingly powerful and potentially destructive technologies. The fourth and final chapter explores the phenomenon of 'railway spine', the obscure nervous condition supposedly suffered by railway accident victims who had seemingly received no actual organic injury, but nonetheless displayed nervous, mental and physical symptoms of serious bodily disorder.

Les médecins cherchent à résoudre les problèmes de santé posés par des individus. Une solution individualisée tient compte de la singularité du patient concerné. L'individualisation des pratiques est-elle possible et souhaitable? Le cas échéant, selon quelles modalités peut-elle ou doit-elle être réalisée'? La première partie de la thèse vise à montrer: que la question se pose depuis les premières théories de la décision médicale (Hippocrate) ; qu'elle s'est posée de façon aiguë au début du XIX" siècle, avec l'apparition des études statistiques; et que l'observation médicale et son évolution concrétisent la façon dont la documentation des cas et leur individualisation interagissent. La deuxième partie reprend la question dans le contexte contemporain, à travers la naissance de l'"evidence-based medicine", ses critiques et son évolution. La troisième partie montre que l'articulation du raisonnement par règles et du raisonnement par cas modélise de façon opérationnelle une démarche raisonnée d'individualisation des décisions médicales. Ce modèle simple permet de rendre compte du mouvement d'aller-retour entre deux conceptions de l'individualisation et d'en proposer une version équilibrée, mise à l'épreuve dans les domaines de l'évaluation des pratiques et de la littérature médicale. / Physicians try to solve health problems of individual patients. Customized solutions take into account the uniqueness of the patient. Is the individualization of medical decisions possible and desirable'? If so, how can I tor should it be performed? The first part of the thesis shows: that the question arises since the first conceptualizations of medical reasoning (Hippocrates); that is was much debated in the early nineteenth century, when statistical studies were first performed to guide medical decisions; and that the medical observation and its evolution materialize how case documentation and management interact. The second part addresses the issue in the current context, from the birth of evidence-based medicine, its cri tics and its evolution. The third part shows that linking rule-based and case-based reasoning adequately pictures the process of customizing medical decisions. This simple model can account for the movement between two kinds of customization and leads to a balanced approach, tested in the field of practice evaluation and medical literature.