![of the mucous membrane lining the whole alimentary canal, is
vitiated, as is proved by the unnatural quantity, colour, and fetor of
the evacuations; the urine likewise is altered in appearance, and the
skin is not more remarkable for the sense of heat, than for that of
dryness and harshness which it communicates to the touch. With the
excitement of the pulse and the increase of the heat, the pain in the
back and limbs and the general febrile uneasiness are much
augmented.
At this period, then, the fever is fully formed; the series of morbid
phenomena is complete: any thing more that happens is referrible to
degree and to duration, and must be the result of one or other of
these circumstances, or of their combined operation. And we now see
that the organs affected, constitute precisely that system of organs
which has been described as forming the febrile circle: that the
symptoms which denote the fever are just the symptoms which
indicate a derangement in the several functions performed by these
organs; and that the order in which they become successively
involved is exactly that which has been assigned.
As soon as the preternatural heat comes on, pain begins to be felt
in the head. Dr. Clutterbuck, in describing the general character of
the ordinary fever of London states[23]
that “the first symptom almost
invariably complained of is more or less of uneasiness of the head.” If
by uneasiness he meant pain, there is, if there be any truth in the
preceding observations, a long train of symptoms to intervene before
this symptom occurs. That it does ultimately occur is certain: but
commonly its place in the series is much later than is here assigned:
it is disordered function of the brain, indicated by loss of mental
energy, that appears to form the first symptom in this morbid train.
The pain, when it does come, is sometimes slight at first, and
occasionally it remains slight throughout the disease; at other times
it is pretty severe. Cases sometimes occur, in which, instead of pain,
there is only a sense of giddiness, and now and then the uneasy
feeling is described as that of lightness: or, on the contrary, as that of
heaviness or weight. But whether the feeling be pain, and that pain
be slight or severe, or whether it be giddiness, or lightness, or
heaviness, it indicates a similar condition of the organ, and requires
a similar treatment.](https://image.slidesharecdn.com/25194-250301110316-95a28cba/85/Innovation-and-the-Creative-Process-Lars-Fuglsang-56-320.jpg)
Innovation and the Creative Process Lars Fuglsang
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- 6. Innovation and the Creative Process
- 7. NEW HORIZONS IN THE ECONOMICS OF INNOVATION Founding Editor: Christopher Freeman, Emeritus Professor of Science Policy, SPRU – Science and Technology Policy Research, University of Sussex, UK Technical innovation is vital to the competitive performance of firms and of nations and for the sustained growth of the world economy. The economics of innovation is an area that has expanded dramatically in recent years and this major series, edited by one of the most distinguished scholars in the field, contributes to the debate and advances in research in this most important area. The main emphasis is on the development and application of new ideas. The series provides a forum for original research in technology, innovation systems and management, industrial organization, technological collaboration, knowledge and innovation, research and development, evolutionary theory and industrial strategy. International in its approach, the series includes some of the best theoretical and empirical work from both well- established researchers and the new generation of scholars. Titles in the series include: Technological Systems and Intersectoral Innovation Flows Riccardo Leoncini and Sandro Montresor Inside the Virtual Product How Organisations Create Knowledge Through Software Luciana D’Adderio Embracing the Knowledge Economy The Dynamic Transformation of the Finnish Innovation System Edited by Gerd Schienstock The Dynamics of Innovation in Eastern Europe Lessons from Estonia Per Högselius Technology and the Decline in Demand for Unskilled Labour A Theoretical Analysis of the US and European Labour Markets Mark Sanders Innovation and Institutions A Multidisciplinary Review of the Study of Innovation Systems Edited by Steven Casper and Frans van Waarden Innovation Strategies in Interdependent States Essays on Smaller Nations, Regions and Cities in a Globalized World John de la Mothe Internationalizing the Internet The Co-evolution of Influence and Technology Byung-Keun Kim Asia’s Innovation Systems in Transition Edited by Bengt-Åke Lundvall, Patarapong Intarakumnerd and Jan Vang-Lauridsen National Innovation, Indicators and Policy Edited by Louise Earl and Fred Gault Innovation and the Creative Process Towards Innovation with Care Edited by Lars Fuglsang
- 8. Innovation and the Creative Process Towards Innovation with Care Edited by Lars Fuglsang Department of Communication, Business and Information Technologies (CBIT), Roskilde University, Denmark NEW HORIZONS IN THE ECONOMICS OF INNOVATION Edward Elgar Cheltenham, UK • Northampton, MA, USA
- 9. © Lars Fuglsang 2008 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or photocopying, recording, or otherwise without the prior permission of the publisher. Published by Edward Elgar Publishing Limited Glensanda House Montpellier Parade Cheltenham Glos GL50 1UA UK Edward Elgar Publishing, Inc. William Pratt House 9 Dewey Court Northampton Massachusetts 01060 USA A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Innovation and the creative process : towards innovation with care / edited by Lars Fuglsang. p. cm.— (New horizons in economics of innovation series) Includes bibliographical references and index. 1. Technological innovations—Management. 2. Creative ability in business. I. Fuglsang, Lars. HD45.I53719 2008 658.3’14—dc22 2007029864 ISBN 978 1 84720 387 8 Printed and bound in Great Britain by MPG Books Ltd, Bodmin, Cornwall
- 10. Contents List of figures vii List of tables viii List of boxes ix List of contributors x Foreword xiv Jon Sundbo INTRODUCTION 1. Innovation with care: what it means 3 Lars Fuglsang PART 1: INVOLVEMENT 2. Innovation and involvement in services 25 Jon Sundbo 3. Customer Relationship Management (CRM) as innovation: taking care of the right customers 48 Jan Mattsson 4. Innovation with care in health care: translation as an alternative metaphor of innovation and change 57 John Damm Scheuer PART 2: IMPORTANCE 5. The public library between social engineering and innovation with care 87 Lars Fuglsang 6. Getting waste to become taste: from the planning of innovation to innovation planning 112 Gestur Hovgaard 7. Public innovation with care: a quantitative approach 131 Lars Fuglsang, Jeppe Højland and John Storm Pedersen v
- 11. 8. Meta-innovations on strategic arenas: innovative management in public organizations 142 Jørn Kjølseth Møller PART 3: POSITIONING 9. The interaction between public science and industry, and the role of the Øresund Science Region’s platform organization 169 Povl A. Hansen and Göran Serin 10. The role of a network organization and Internet-based technologies in clusters: the case of Medicon Valley 193 Ada Scupola and Charles Steinfield 11. The “Mad Max Puzzle”: positioning and the lone inventor 212 Jerome Davis and Lee N. Davis PART 4: SENSEMAKING 12. Sense caring in innovation 237 Peter Hagedorn-Rasmussen 13. Making innovation durable 254 Connie Svabo 14. Intrapreneurship: differences in innovations is a matter of perspective and understanding 275 Hanne Westh Nicolajsen 15. Mindful innovation 295 Poul Bitsch Olsen Index 311 vi Contents
- 12. Figures 8.1. System of innovation on the domain for educational services in Denmark (kindergartens and services for care of children) 154 8.2. Diversity and capability to innovate 159 8.3. Organizational cultures 161 9.1. The Øresund Science Region 180 11.1. Initial positioning: Mad Max and Big Widget Inc. 215 11.2. Mad Max and Big Widget Inc. The impact of expectations 217 11.3. Time line one: two-step sequencing 219 11.4. Time line two: multiple step sequencing 219 13.1. Communication (a) 270 13.2. Communication (b) 270 14.1. The innovation process of ProjectWeb 281 14.2. Screen dump from ProjectWeb (IT department) 282 14.3. Innovation-in-use? 283 vii
- 13. Tables 4.1. Quantitative and qualitative approach to quality development 71 7.1. Innovation in public institutions 134 7.2. The proxy of innovation with care 135 7.3. Innovation and fulfillment of external demands 136 7.4. Innovation and strategic involvement 137 8.1. Institutional pressures on educational organizations 145 8.2. Examples of strategic arenas in educational organizations (kindergartens) 149 8.3. Characteristic of networks as a potential and as action (intention) 162 10.1. Characteristics of Medicon Valley (adapted from the MVA home page, www.mva.org) 202 11.1. Chronology: Kearns v. Ford re: the intermittent windshield wiper 226 14.1. ProjectWeb content and sense-making conditions across projects 289 viii
- 14. Boxes 8.1. Types of innovations and innovation strategies in the public sector 151 8.2. Five roles in the management of innovation 158 12.1. The products offered – and a taste of the unfolding innovation 244 12.2. The e-realtors’ four IT platforms 246 15.1. Definition of mindfulness 300 ix
- 15. Contributors Jerome Davis is currently Canadian Research Chair (Oil and Natural Gas Policy) at Dalhousie University, Halifax, Nova Scotia. He has published widely in the fields of oil and natural gas policy, and in diverse fields such as equity markets as institutions, the institutional consequences of incom- plete contracts, project management and analysis, public sector restructur- ing, and the role of prizes as incentives to innovation. Lee N. Davis is Associate Professor at the Department of Industrial Economics and Strategy, and Research Associate at the Centre on Law, Economics and Financial Institutions, both at the Copenhagen Business School. She has conducted research on economic incentives to research and development over the past two decades, with a special focus on the role of intellectual property rights, and published widely in the field. Other research interests include firm appropriability choices, innovation strategy, and aca- demic patenting in the life sciences. Lars Fuglsang (PhD) is Associate Professor in Social Sciences at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. He has written books and articles in the field of innovation studies, public innovation, service development, and science and technology studies. His research explores how organizational frame- works are created to deal with the impact of innovation and technology on business and society. Peter Hagedorn-Rasmussen (PhD) is Associate Professor of Social Sciences at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. He has written books and articles in the field of organizational change, management and work life studies. His main research interest is the study of organizations as living compromises, with particular focus on the relationship between manage- ment and work life. Povl A. Hansen is Dr fil. in Economy History from Lund University, Sweden, and Associate Professor in Economic Geography at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde x
- 16. University. He has published in the fields of technology, innovation and regional development. His research is in the field of industrial analysis espec- ially focusing on the relationships among innovation processes, industrial structures and transfer of knowledge. He has published many books, reports and articles on technology, business conditions and regional development. Jeppe Højland is a doctoral student of Social Sciences at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. His PhD dissertation is about new kinds of reward practices in knowledge-intensive firms. He has written an article about the impact on leaders and employees of the Danish public sector reform. His main research interest is innovation within the area of human resource management. Gestur Hovgaard (PhD) is Assistant Professor of Social Sciences at Roskilde University. He has written in the field of innovation and social innovation, and his main fields of interest are within local and regional development. Food chains and food biotechnology are also examined in his research. Jan Mattsson is Professor in business administration at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. He has held several professorships and visiting pro- fessorships in New Zealand, Australia and Scandinavia. He has authored several books and more than 50 peer-reviewed international publications in journals such as The International Journal of Research in Marketing and Journal of Economic Psychology. He serves on many editorial boards of international journals in marketing and services. He takes part in several international research projects focusing on customer-firm interactions. Jørn Kjølseth Møller (Master of Political Science) is a doctoral student of Social Sciences at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. He has written books and articles in the field of strategic management and change, service development and psychology in organizations. His main research interest is in strategic management and change of educational organizations in the public sector. Hanne Westh Nicolajsen (PhD) is Assistant Professor at the Center for Information and Communication Technologies (CICT) at the Technical University of Denmark. She has published in the field of the use of infor- mation and communication technologies in organizations. Her research Contributors xi
- 17. examines how information and communication technologies are used in organizations and are shaped by organizational and entrepreneurial factors. Poul Bitsch Olsen (PhD) is Associate Professor of Organization Theory at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. He has written books and articles on collective knowing and organizing. In particular, his research examines leadership and project work. His research also explores how col- lective practicing is the basis for business innovation, team-sports, value production and academic competence. John Storm Pedersen (PhD) is Associate Professor of Social Sciences at the Department of Society and Globalisation at Roskilde University. He has written books and articles in the field of public administration and man- agement, structural reforms in the public sector and public innovation. His main research interest at present is the impact of the structural reforms in the public sector in Denmark and how public institutions deliver services to the citizens. Pedersen is former CEO of the Mayor’s Office in the munici- pality of Aalborg. John Damm Scheuer (PhD) is Assistant Professor at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. His main research interest and focus is the study of the encounter of innovative ideas and local practice in private as well as public organizations. The encounter is studied as implementation, diffusion or translation processes. But also new and innovative ways of theorizing about “the encounter” and local organizing processes are explored. Ada Scupola (PhD) is Associate Professor at the Department of Communication, Business and Information Technologies (CBIT), Roskilde University. She has published articles and books in the area of information technology innovation, especially in the field of adoption, diffusion and use of information technologies such as e-commerce and e-services in SMEs and industrial clusters. Her research focuses primarily on how organiza- tional and industrial factors shape the development, adoption, implemen- tation, use, and effects of such technologies. Göran Serin (Dr) earned his degree in Economic History and is Associate Professor in Business Administration at the Department of Communication, Business and Information Technologies (CBIT), Roskilde University. He has extensive research experience within the fields of technology, innovation and regional development. He has a particular interest in industrial analysis and xii Contributors
- 18. industrial restructuring and regional development, on which he has pub- lished many articles and books. In recent years, his research has especially focused on analysing regional integration in cross-border regions. Charles Steinfield (PhD) is Professor and Chair of the Department of Telecommunication, Information Studies and Media at Michigan State University. He has published books and articles in the area of organizations and use of information and communication technologies. His research examines how individual and organizational factors shape the development, adoption, use and effects of such technologies. Jon Sundbo is Professor in Business Administration at the Department of Communication, Business and Information Technologies (CBIT), Roskilde University. He is director of the Center for Service Studies and coordinator of the Department’s research area in innovation and change processes in services and manufacturing. He has published extensively in the fields of innovation, service management and the development of the service sector, tourism and organization. He has published articles in several journals on innovation, entrepreneurship, service and management and has authored several books, among these The Theory of Innovation and The Strategic Management of Innovation. Connie Svabo (Master in Business Administration) is PhD Fellow at the Department of Communication, Business and Information Technologies (CBIT) at Roskilde University. She has written articles and edited books about practice-based learning. She has several years of professional expe- rience in consultancy work and commercial writing. Her main research interests are organization, materiality and esthetic forms of knowing. Contributors xiii
- 19. Foreword This book presents new thoughts and research on innovation. Innovation with care emphasizes both the care for people and the care for doing inno- vation in a proper way. Most innovative attempts fail and create economic loss and individual disappointment. Another book in the overwhelming stream of books on innovation? Can it contribute with new knowledge? We believe it can by taking a primarily sociological approach to innovation. Not that the economic aspects are forgotten, but the sociological aspects are emphasized complimentary to the economic ones. This is not very common in innovation literature. The individual – the entrepreneur – has been emphasized, but rarely the social processes with different actors and roles and innovation as an interactive process. In the increasing contemporary theoretical and practical interest for innovation, the social aspects of the innovation process has often been for- gotten. Emphasis has primarily been on economic processes and policy. However, innovation is a process that is carried out by people in interaction with people. It may be that the result of the process is part of the market economy, but the process itself is a social process where the economic results are not at all sure. Recently the social processes have come more into focus. Innovation projects, creativity and user-involvement have become objects in the front research. This book is one contribution to this movement. The book is a presentation of more than 15 years of research in the Innovation Research Group at Roskilde University in Denmark. In this group we have had a preference for the out-of-mainstream approaches to innovation: Innovation in services and the experience economy, innovation as non-sophisticated, quick practical ideas, continuous incremental inno- vation, user/customers’and employees’role in the innovation process, inno- vation as an organizational sensemaking process and so on. This has been amusing and informative for us and we believe it can provide new knowl- edge for researchers, students and others interested in innovation as both an economic and a social phenomenon. We think that the future for the phenomenon of innovation – and thus for innovation research and practical innovation work in firms and societies – is to return to the original point of departure: A general change of behav- ior and economic structures – social and economic change. We believe that xiv
- 20. innovation in the future will be a much more comprehensive phenomenon than just R&D, entrepreneurship as establishment of new high-tech firms or narrow industrial policy. Social entrepreneurship as solving social prob- lems, innovation as a value creating organizational development factor and as a collective social activity in- or outside the formal economy will prob- ably be future highlights within innovation research. This will develop inno- vation theory and make it more exciting, but also more diffuse since it will concern social change in general. The latter will challenge the theory devel- opment, but there is no way around this if we want to explain economic development, which in the future will concern phenomena such as lifestyle, experience, corporate identity, solution of social problems and so on. Jon Sundbo Professor of Innovation and Business Administration Co-ordinator of the Innovation Research Group Roskilde University, Denmark Foreword xv
- 22. Introduction
- 24. 1. Innovation with care: what it means Lars Fuglsang The purpose of this book is to find new ways to understand and analyse the phenomenon of innovation within the frameworks of “strategic reflex- ivity” (Sundbo and Fuglsang, 2002; Fuglsang and Sundbo, 2005) as well as “open innovation” (Chesbrough, 2003). The book presents new insights into mechanisms that are important for benefiting from innovation across sectors, organizations and people. It deals with tensions and paradoxes in innovative activities between, for example, variety and selection, crea- tivity and innovation, or between business innovation and social innova- tion – rather than seeing innovation from one particular point of view. “Innovation with care” means that innovation is seen as something that takes place among many actors having different perspectives, ideas and cul- tures that have to be carefully woven together in order to achieve the benefits of innovation. We understand innovation as an interactive process that involves many people and often also changing people across sectors. Innovation is there- fore a common activity, which is not restricted to special groups of persons such as “the creative class”or “symbol analysts”or people working in R&D labs. Innovation is a process that increasingly engages ideas and opinions from many different people. These are opinions and ideas that have to be expressed but also selected and aggregated. Innovation requires diversity and collectivity at the same time, and the balance between the two is a crucial aspect of innovative activities today. This balance is affected both by the market and by other social and organizational forces. We examine how social and organizational forces are important to that balance and these tensions. In doing so, the book tries to distinguish between different organizational and societal mechanisms of diversity and collectivity, especially four. These are: involvement, importance, position- ing and sensemaking. These all operate on different levels (micro and macro) that can be understood and analysed from a sociological and eco- nomic perspective (see later). Involvement is a mechanism of diversity mostly at the organizational level, where people can deliberately involve others in an exchange of experi- ences and considerations of workable ideas. Involvement presumes that 3
- 25. those who are involved are relatively independent and can speak freely about their opinions. Importance is a mechanism of collectivity. It presumes that certain init- iatives are seen as better than others and therefore are exposed and diffused more widely, so that people can adopt them or learn from them. The notion of importance also implies that we are here not only speaking of the market mechanism, but also of mechanisms that involve an element of voice (not just choice). Hence, importance is a social mechanism of aggregation, selec- tion and diffusion. Positioning is a mechanism of diversity at the societal level. It requires that people have the freedom to pursue their economic and social interests and can express their opinions about ideas they perceive to be socially effective or desirable. According to this mechanism, people can position themselves as actors in innovation and economic development. Finally, sensemaking is a mechanism of collectivity at the micro-level, where people try to make sense of their experiences and thereby to discover, not so much what is perceived as important and wise in the larger context, but what is appropriate and meaningful in a specific context. The different chapters of the book deal in different ways with these crosscutting aspects of innovation. Some have a stronger focus on the macro-level and some on the micro-level. Some tend to stress diversity and others collectivity. Therefore, the chapters have been grouped in different sections entitled involvement, importance, positioning and sensemaking. Nevertheless, what binds together all of the chapters is the attempt to see innovation from a broader perspective and at the systemic level where the tensions between actors, and between diversity and collectivity, can be studied. BACKGROUND Innovation with care is generally an approach to innovation that starts from the following premises: 1. that innovation and the way in which innovation takes place is import- ant to economic growth and social development; 2. that the concept of innovation has to be better understood in terms of how it can be applied in practice, especially through case-studies; and 3. that innovation in practice requires a reflexive approach that takes into account both economic and social elements, as well as tensions across sectors, organizations and people. 4 Introduction
- 26. Innovation with care grows out of research undertaken at Roskilde University over recent decades. This research has focused upon how inno- vation is changing from a technological and industrial mode to a reflexive mode involving many types of institutions, sectors, companies and social groups (Fuglsang and Sundbo, 2005; Sundbo and Fuglsang, 2001). This calls for a new conceptualization of innovation as well as social develop- ment, which can take into account the heterogeneity of relationships that evolve around innovative activities. Today, the innovative resources are much more widely distributed throughout society than just a few decades ago (Chesbrough, 2003). Innova- tion is no longer based in companies’ R&D departments, or in the state’s large-scale projects. Innovation can be understood as an interactive process that involves many and changing actors over time, and which serves mul- tiple concerns and conglomerates of different users. This also makes it more challenging for people to integrate different ideas and opinions about inno- vation, to balance goals and means, and to create frameworks of mutual communication, collaboration and understanding. It becomes critical to analyse how this heterogeneity among sectors, organizations and people can be managed in different ways, and in different social and strategic arenas. This historical approach to innovation can also be seen as being opposed to a more homogeneous approach to innovation where innovation is seen as something which is planned and managed in a more straightforward and detailed way. The heterogeneity of innovation today means that innov- ative activities cannot be easily controlled through detailed planning, but that opportunities for innovation have to be continuously evaluated, inter- preted and interfered with. Innovative organizations become interpretative systems (Daft and Weick, 1984; Fuglsang and Sundbo, 2005). They try to create some sense of direction and integrate people into changes by making interpretations about the changing opportunities of the organization, and how skills and opportunity can be adjusted to each other. The main question, which should be explored, is therefore how a proper environment for innovation can be constructed that takes into account these complex mechanisms of diversity and collectivity. Furthermore, an approach that uses various types of case studies in combination with other research techniques may turn out to be an important way in which such mechanisms can be better understood. It requires a more problem- and action-oriented approach to the study of innovation. The purpose of the book is to demonstrate that this approach is a fruit- ful approach to innovation. Along these lines, innovation is, in our view, more about interpretation than planning, more about heterogeneity and tension than homogeneity and control, more about opinion than choice, Innovation with care 5
- 27. and more about wisdom than science. The book will illustrate the value of innovation with care through a number of interesting cases. CREATIVITY AND INNOVATION In most definitions of innovation, innovation consists of two aspects: creativity and innovation (Amabile et al., 1996), invention and diffusion (Rogers, 1995), exploration and exploitation (March, 1991), or variation and selection (Nelson and Winter, 1977). This means that innovation is seen as consisting of two integrated processes. New appropriate ideas or inventions have to be explored in a creative way. In addition to this, there is another parallel process going on where these ideas are aggregated, selected, diffused, implemented and exploited. The interaction between these two sides of innovation is critical. For example, Teresa Amabile, who has studied creativity, defines inno- vation in the following way. “We define innovation as the successful imple- mentation of creative ideas within an organization. In this view, creativity by individuals and teams is a starting point for innovation; the first is neces- sary but not sufficient condition for the second” (Amabile et al., 1996: 1154–5). Mulgan and Albery who have studied public and social innovation have defined innovation in a similar vein: “We define innovation as ‘new ideas that work’. To be more precise: Successful innovation is the creation and implementation of new processes, products, services and methods of deliv- ery which result in significant improvements in outcomes efficiency, effectiveness or quality” (Mulgan and Albury, 2003: 3). And Sundbo (1998: 12) in a book about service innovation gives the fol- lowing definition: “I will use ‘innovation’ to describe the effort to develop an element that has already been invented, so that it has a practical- commercial use, and to gain the acceptance of this element.” Most of these definitions of innovation have their origins in Schumpeter’s original definition of innovation in his Theory of Economic Development. In that book, Schumpeter is, among other things, conceiving the function of the entrepreneur for economic development as someone who goes against the mainstream. In his definition of innovation, Schumpeter stresses both the ability of the entrepreneur to create entirely “new combinations” and to open up new markets and teach the consumers to use innovations (Schumpeter, 1934, 1969: 65–6). This double sidedness of innovation is at the core of this book as it is also the core of many descriptions of creativity. For example, in his book about creativity, Csikszentmihalyi makes a distinction between the domain of 6 Introduction
- 28. creativity and the field of creativity (Csikszentmihalyi, 1996). The domain is the specific area in which someone is creative, for example in science, art or politics. The field is the wider environment in which creativity is recog- nized and stimulated. It is often the field of innovation, rather than the domain, which explains, according to Csikszentmihalyi, why some organ- izations are more creative than others, for example why Florence was a par- ticular creative city in the Florentine renaissance. On the other hand, in this approach, we should not ignore the critical factors that are important to creativity or the social psychology of creativity. For example, in her work on the social psychology of creativity, Teresa M. Amabile has examined the proposition that intrinsic motivation is crucial to creativity (Amabile, 1996). Creativity is, as Schumpeter explained, an act that is often motivated by itself rather than by external requirements or extrinsic motivations. Creativity also requires that people are situated in a domain where they possess the necessary domain-relevant skills – rather than being put into a domain where they possess no such skills. To treat creativity with care means that people are not moved to a domain where they possess no domain relevant skills, and that intrinsic motivation is not entirely replaced by extrinsic motivation. This may increase the chances that creative results are appropriate and not bizarre or eccentric. In this way creativeness means the ability to create new innova- tive results that are meaningful and appropriate. Understood in this way, the right microenvironment for creativity increases the chances of creative ideas that are also appropriate to innovation. BUSINESS INNOVATION AND SOCIAL INNOVATION Innovation with care is also an approach to innovation which focuses upon the interdependencies that exist within social and economic development between business innovations on the one hand, and “social innovations”on the other – in addition to the interaction of creativity and innovation. In the perspective of social innovation, the relation between creativity and innovation, variation and selection, gains another meaning, as we shall briefly explore in the following. Social innovations are innovations based in social goals and social processes. Social innovation (Young Foundation, 2006) and business inno- vation, however, often overlap and intertwine. A mobile telephone is a social innovation and a business innovation at the same time: it serves a social goal for those who use it, and it generates economic value for those who produce it and for society. A new model of a mobile telephone is perhaps not necessarily a social innovation if it does not serve a particular (new) Innovation with care 7
- 29. social goal. To understand and analyse the social goal and value of an inno- vation can be an important driver of business innovation. Another aspect of social innovation besides the social goal and social value is the social process and diffusion of innovation. All processes of innovation, business innovations, social innovations or innovation with care, could, as indicated, be said to consist of two related processes: explor- ation and exploitation (March, 1991), variation and selection (Nelson and Winter, 1977), or invention and diffusion (Rogers, 1995). Ideas are devel- oped, and then some of these ideas are selected and scaled up as more important or wiser than others. The selection mechanism can be “the wisdom of the crowds” (Surowiecki, 2004), or it may be opinion-makers or society’s elite that attempt to “pick the winner”. Seen from the perspective of business innovation, the market mechanism is crucial to this tension and the transition between invention and diffusion. The “wisdom of the crowd” is here expressed by consumer choice implying that certain ideas are picked by the crowd as being more effective or in some sense better than others. Seen from the perspective of a social innovation and innovation with care, the market is not the only mechanisms of dif- fusion and scaling up. Here, other social mechanisms of aggregation, selec- tion and diffusion are important too (see Rogers, 1995), and these are sometimes more difficult to come to grips with from an analytical point of view. In some cases, as in public innovation, the market mechanisms may be entirely missing, and therefore the social mechanisms of aggregation, selec- tion and diffusion of innovation present an even more challenging task when analysing it at the theoretical level and constructing it at the practi- cal level. For example, the market mechanism cannot always be applied to the selection of adequate learning or teaching tools in schools. Here, inputs from many professionals and experts and even systemic reviews and demonstrations of these inputs may be needed as a basis for selection. In other cases, the social selection and diffusion of innovation is intertwined with some kind of market mechanism, where the behavior of the user and user choice in combination with user voice may be relevant. This is typical for public television for example. Innovation with care is therefore an approach to innovation that tries to pay more attention to social mechanisms of diffusion and scaling up than is usual, and to analyse the complex interactions that take place between market mechanisms and social mechanisms, understood as a mechanism of selection and diffusion. In some cases, business innovations and social innovations, as men- tioned, strongly overlap. In other cases social innovations are separate domains but still crucial to business innovation. The university is a social 8 Introduction
- 30. innovation in its own domain, which still plays a crucial role for economic and social development more broadly. Health is dependent on development of commercial drugs as well as a range of social innovations including the health system itself. The sewerage system is a social innovation that is crucial for health conditions. Wikipedia is a social innovation that may end up as a commercial innovation, but initially it started out as a social idea. Social innovations, such as a library or a laboratory, provide social struc- tures that inform the chances of discovery, creativity and innovation more broadly in society. In some cases, social innovations are therefore domain specific, in other cases they provide a different perspective on business innovation, as in the case of the mobile phone or the use of SMSs. The practical relevance of this approach is that there is a difficult balance to maintain within social and economic development between market mechanisms on the one hand, and social mechanisms of innovations on the other. Furthermore, it becomes important to investigate how social mechanisms can be constructed. More energy and resources could be devoted to the study of the social sides of innovations because they are crucial to innovations both to the chances of creative discoveries and to the robust and meaningful application and implementation of these dis- coveries in business and society. As such, social mechanisms of innovation also inspire economic development more broadly and can be pertinent to the implementation and the commercial exploitations of innovations. Innovation with care is in this way really a broad concept for the produc- tive tensions and balance between the commercial and the social sides of innovation. Innovation with care is also an approach to innovation which is different from social engineering. Innovation with care represents, as we define it, an incremental way to improve society and its institutions, and is based in the social values and independent opinions of many citizens in the context of, for example, a nation, that have to give their support to it. It corresponds more or less to Karl Popper’s idea of “piecemeal”social change as opposed to utopian social engineering, hence it is a critical-reflective and incremen- tal approach to innovation (see Popper, 1962). Innovation with care is a complex and a time-consuming process where much can go wrong, because of the many unintended consequences and risks associated with innovation. Therefore, we need a careful approach to innovation where many perspectives and ideas are woven together in a careful way. Another important issue here is that innovation can be motivated in many ways as Schumpeter already pointed out in his Theory of Economic Development. Profit is one motive, but the creation of a small kingdom or the wish to solve concrete problems could be other reasons for people to Innovation with care 9
- 31. engage in innovation. Many important innovations cannot, initially, be, in a meaningful way, understood directly as commercial innovations, driven by profits, since their “business model” sometimes is very unclear. Google and Wikipedia are two prominent examples. Other examples are those development projects that take place in the name of cultural policies. For example, when politicians, volunteers, business leaders and social entrepre- neurs go together to develop their municipality, the direct commercial spin- offs are usually very difficult to calculate and understand. This kind of innovation is better described as a social innovation of its own purpose and in its own right that may be complementary to business innovations in the municipality, for example the well functioning of the labour market and the chances of creativity and meaningful innovation. Social innovations such as schools, universities, libraries, and so on can be driven by public or private organizations. Voluntary organizations or enthusiasts as well as business organizations can also drive social inno- vations, and sometimes we tend to forget the significance of these initiatives. For example, in the case of the so-called information society, the field of social innovations is often much more important to discovering needs and socially effective solutions to them than is normally understood. Social or public entrepreneurs and social institutions can play a crucial role for devel- oping network technologies to people that eventually become real resources to them. These kinds of innovations can inspire business innovations and can lead to the development of highly meaningful commercial innovations. But the field of social innovations is very poorly understood today in com- parison with many other high-profile commercial innovations. There is a hidden economy of social and volunteer innovation at risk here, which needs to be explored in order to identify good examples of socially effective ideas that others might be able to learn from. A main difficulty within the field of social innovation and innovation with care is, however, that the impact of this approach is difficult to define and measure. For example, what is the impact of the university? What is the impact of the library and the school? It can be explained in broad terms, but it is much more difficult to measure and analyse than commer- cial innovations. Indeed, in some cases, certain success criteria can be created, such as the impact of the health system or a particular medical treatment on life expectancy. Still, even in this case, the complex interaction of treatment, sanitary conditions and nursing are very difficult to explain. And in many other cases, the measurement of impact is a very difficult issue. Furthermore, the impact of social innovation and innovation with care on business innovation is an extremely complicated issue in itself. For example, what is the impact of the public library on business innovation? Does it in one way or another improve the quality of the work force? 10 Introduction
- 32. But these difficulties of measuring the impact of social innovation should not mean that we neglect to throw more light on these issues and their cri- tical impact on society. SCHUMPETER I, II AND III Our approach to innovation is partly inspired by the tensions in Joseph Schumpeter’s work between his early work, so-called Schumpeter I, and the late work, so-called Schumpeter II (see Phillips, 1971 for a discussion). One might say that our approach is an attempt to formulate a Schumpeter III approach that reconsiders the wider context of innovation. In the early work, Schumpeter stressed the role of the entrepreneur (Schumpeter, 1934, 1969). The entrepreneur is described as a special type of person with a special motivation, which is not necessarily driven by profits. The entrepreneur is a dynamic person outside the mainstream, and has a function for changing economic structures. In his later work, by contrast, Schumpeter thought that the social function of the entrepreneur had disap- peared (Schumpeter, 1947). He thought that innovation had become a routine-activity in the labs of the modern business corporation. Schumpeter claimed that the entrepreneur was no longer a very relevant type since inno- ation had become more integrated into society. The particular distinction between the entrepreneur and routine-based innovation in Schumpeter’s work is important here. But what also matters is that Schumpeter’s work tells us that different forms or modes of inno- vation exist, such as the entrepreneurial form in the late nineteenth and early twentieth centuries and the routine-based form in the mid-twentieth century. Furthermore, there may be different motives and rationales behind the various approaches to innovation as well. What we are missing in Schumpeter’s work is, perhaps, a recognition that these two forms of innovation may exist at the same time and in some ways are interdependent. Schumpeter, by contrast, seems to think that one his- torical period (that of heroic entrepreneurs) is being entirely replaced by another (that of the large corporations). Clearly, from what we know today, this is wrong. There is still a function for entrepreneurs, and today new forms of entrepreneurship are being promoted, such as social entrepre- neurship and public entrepreneurship. They have, however, to be under- stood at the systemic level rather than at the level of the individual. The distinction between Schumpeter II and Schumpeter III is of the same character as the distinction between Schumpeter I and Schumpeter II. These three approaches represent different frameworks of innovations, where innovations proceed in different ways, are motivated by different factors, Innovation with care 11
- 33. aggregated, selected and diffused in different ways, and often crystallize into different kinds of institutions with different underlying rationales. What we argue, along with Chesbrough (2003), is that innovation today is no longer only based in the routines of R&D inside large corporations. But we also argue that this leads to the formation of new mechanisms of creativity and diffusion of innovation that can be understood at the systemic level. In the field of science studies, Nowotny and others have been discussing so-called mode II science, where external requirements come to play a growing role (Nowotny et al., 2001). They use the metaphor of “agora” to describe how a public arena of science is formed where the quality and the relevance of science is being discussed by scientists as well as by citizens and politicians. In the same way we argue that a new mode of innovation is emerging, the Schumpeter III approach, where new mech- anisms of creativity and diffusion of innovation are becoming important, and where market mechanisms and social mechanisms are blended in new ways. For example, we argue that new strategic arenas of innovation are being formed to which many types of actors are linked, such as universities, companies, government institutions and user groups. Furthermore, emp- loyees and consumers are interlinked in new ways at the systemic rather than only the individual level. One important expression of Schumpeter III that we want to stress in this book is innovation in services. Service providers are very dependent on their front personnel and their ideas, because the services are often co- produced by the consumer and co-consumed by the provider, and the con- crete work that goes into this is often difficult to describe in very precise terms. Some innovations in services are indeed business innovations, but many innovations may be better explained as social innovations in the sense that they are more related to the problem-oriented work of the front per- sonnel than directly to a commercial strategy. It is based in the interpre- tation and understanding of a situated problem. This problem-orientation can also often be interlinked with the life-story, intrinsic motivation and professional pride of the service-worker. Of course, the clever service provider will try to involve the service worker as much as possible in the business development, because he wants “ideas that work” (Mulgan and Young) drawn from the experience of the service worker. This becomes even more crucial today under the new ‘Schumpeter III paradigm.’ The employee and the consumer therefore become more and more involved at the systemic level in innovation activ- ities, rather than they are interacting and developing services only in indi- vidual face-to-face-relationships. Both in the private and in the public sector, the “journey to the interface” becomes an important theme (Parker and Heapy, 2006), that is the journey 12 Introduction
- 34. to the interface between the front personnel and the consumer. Experiences in the front have to be explored and collected in a more systematic way. In this journey, the interpretation and understanding of the needs of the consumer and the social goals involved in consumer behavior in a broader sense becomes crucial. In the “journey to the interface” the knowledge and experi- ence of the front-personnel is therefore also critical. At the same time, the front-personnel are seen as people who should not act on their own, but on behalf of the system (see Parker and Heapy, 2006). In this way, the issue becomes one of how people can learn from each other and how the good ideas can to be scaled up and diffused across and between people in organizations. This systemic orientation towards external ideas and their combination with internal experiences is an important aspect of the Schumpeter III model. The diffusion of the Internet and WEB2 and the many new services that are offered on the Internet provide plenty of examples of innovation with care where the innovative resources are highly distributed and where some innovative ideas are being systematically collected and scaled up, or picked by the crowd or through other mechanisms of selection. For one thing, these services are often developed as social innovations in a community of prac- tice and then eventually they develop into business innovations. Facebook is an example of this (see Ellison et al., 2006). It was initially a network tech- nology inspired by earlier ways to introduce students to each other using photographs in a physical “facebook”. Then it was developed by a student at Harvard University into a worldwide e-based service for students. It will probably evolve into a commercial innovation in time to come. Schumpeter III is a mode of innovation where the interpretation, explor- ation and exploitation of external ideas as well as their combination with internal experiences and ideas become increasingly important (Chesbrough, 2003), and where the diffusion and scaling up of ideas that are thought to be better take new forms in the market as well as society and in organiz- ations, as we shall explore in this book. DIVERSITY AND COLLECTIVITY, VARIETY AND SELECTION Innovation requires diversity and collectivity, variety and selection, cre- ativity and innovation at the same time. The balance between the two sides of the coins is a crucial aspect of innovation – and crucial to this book. This balance we understand as affected both by the market and by other social and organizational forces. The book tries to distinguish between different analytical perspectives that can be helpful for studying these balances or tensions. As a way to Innovation with care 13
- 35. organize the chapters of the book we can discern four broad analytical perspectives. These are as previously mentioned: involvement, importance, positioning and sensemaking. These should be understood as different broad perspectives on diversity and collectivity on different levels. What follows is a brief description of these analytical perspectives that organize the chapters of the book after which the single chapters will be presented. Involvement Involvement means that innovators can seek to involve many opinions and ideas during innovation. Often, for innovation to take place, it is important that employees and users are involved in the exploration of inventions and new “ideas that work.” How this involvement can take place is a compli- cated issue and a fruitful ground for new research as well as case-studies. Involvement is a mechanism of diversity or variety, but it also requires that management carefully selects some of the ideas while others are dis- missed. Hence, involvement requires a careful approach to both variation and selection, or, as it is explained in Sundbo’s chapter, to reflexivity and strategy-making at the same time. Most obviously, employees can be involved in innovation activities. But consumers can also sometimes be involved. For one thing, they can be involved through the employees having many years of experience with con- sumers. The employees’ discovery of consumer needs can sometimes be crucial for improving goods and services. This is true especially in services and public services. In some cases, the exploration of consumer needs may be more difficult than in others. For example, in the public sector, a principle of universal- ism is often important, and employees for good reasons have to think in terms of rules and public law rather than individual needs. To listen more carefully to individual citizens or to make use of employees’ experiences with them may almost constitute a paradigm shift in the public sector. Furthermore, while in many settings involvement of employees and con- sumers may work in the individual case, in the changing context of inno- vation, the involvement of employees and consumers must, as mentioned, increasingly take place in a systemic way. People must learn to act on behalf of the company system rather than on behalf of themselves. This also requires a careful balancing of strategy and reflexivity. Importance Importance stresses the principle that some ideas may tend to become more widely diffused than others. Importance therefore refers to a mechanism of 14 Introduction
- 36. collectivity and selection. It presumes that certain initiatives are perceived as better or more appropriate than others and therefore are recognized by more people, and that people are willing to adopt them or learn from them. The notion of importance also implies that we are not only speaking of the market mechanism, but also of a mechanism that involves an element of voice. The market mechanism cannot always be used to scale up and diffuse important ideas. Thus, in many institutional settings, and in the context of many services, people cannot, in practice, make use of the market mechanism, because they are dependent on the services that are provided where they live and work, such as schools, kindergartens, res- taurants, local cultural offers and so on. To find ways other than the market mechanism to promote experiences, make visible the good ideas and scale up the better initiatives so that others can learn from them is a major challenge for many social and public services. Positioning Positioning means that companies and institutions can position themselves as actors in economic change and innovation. They are not role-takers in a passive way, but they can actively position and reposition themselves in relation to each other. Nevertheless, in the context of increasing complex- ity, it may sometimes be quite challenging to acknowledge and recognize each other’s competences and qualities. Positioning is a mechanism of diversity or variety at the societal level. It requires that people have the autonomy to pursue economic and social interests and can express their opinions about ideas they perceive to be rele- vant – and can communicate what their own contribution to innovation and development may be. Positioning can be thought of as something that takes place both among individual persons and among institutions. For example, classical entrepre- neurship is an embodiment of positioning, where individual persons position themself in relation to other people. But also institutions, such as universi- ties, schools and libraries, have a need to position themselves in order to demonstrate their value to others. Hence, the university is not the same as an R&D lab in a private firm and the public library is not the same as Google (two examples from this book). They each have to position themselves in order to make clear what their individual gift is. How can they do this? Sensemaking Sensemaking means (following Weick, 1995) that there must be room for continuous sensemaking in connection with innovation processes in order Innovation with care 15
- 37. for people to discover and exploit new experiences and ideas and make them intelligible among each other. Managers and employees must create a “mindful environment”where they collectively can make sense of people’s changing perceptions and ideas of social and economic opportunities. Sensemaking is a mechanism of collectivity or selection at the micro- level, where people together try to make sense of changes and thereby to discover, not so much what is perceived as important and wise in the larger context, but what is appropriate and meaningful in a specific situated context. A metaphor for sensemaking, which is used in this book in several chap- ters, is that of “translation.” Translation means that new ideas, goods and services are translated or transformed by people to fit the local context before they can be used. This is critical in the emerging context of open innovation and strategic reflexivity. External ideas have to be adapted to the local context before they can be used, and sometimes, when it is difficult to “translate” them, they must be dropped. Perhaps this is also an approach to innovation that has a particularly strong hold on Scandinavian societies. Here the adoption of ideas, inven- tions and technologies from the outside world, and the attempt to translate them into something locally valuable, has been a critical aspect of eco- nomic development and the development of the welfare states. THE CHAPTERS OF THE BOOK All of the chapters in the book deal with certain tensions or paradoxes in innovation, as described above, which relate to involvement, importance, positioning, or sensemaking. Innovation with care is thus an approach that seeks to analyse and understand how people in empirical cases are dealing carefully with these tensions and paradoxes. In the first section of the book about “involvement,”we investigate tensions between engaging people’s opinions and ideas on the one hand, and the overall strategy of a company or an organization on the other. Jon Sundbo examines tensions in organizations between the involvement of employees in innovation, and care for the overall strategy process of a company or an organization. Sundbo pays attention particularly to inno- vation in services, and his chapter includes a review of the literature on service innovation with respect to the involvement of employees. Sundbo’s chapter also draws on a multiple case approach to service firms. Sundbo concludes that service innovations are based on care for the strategic reflexive processes as well as the actors and roles involved in service production. This care does 16 Introduction
- 38. not only mean the nursing of the people and encouraging intrapreneurship, but also restrictions and a strict decision process concerning new ideas and innovation projects. Jan Mattsson examines tensions in an organization between different facets of care that are important to working with Customer Relationship Management (CRM). Taking care is the physical handling of the CRM innovation process and running the subsequent CRM system. Caring for customers and employees is a psychological sensitivity to how customers and employees react when faced with change and re-organization. Careful operation means that safeguards are in place and care is taken when design- ing the system to ascertain the increased value can be offered to customers in exchange for the extra effort of data input and co-ordination. John Damm Scheuer explores tensions that emerge in an organization when a general idea travels into the organization and is translated into something useful by the people inside that organization. In a case study of innovation in health care (the case of the “clinical pathway”), he argues that the innovation process may be better understood if theorized as a transla- tion rather than an implementation or rationally planned process. Scheuer also argues that the concept of “innovation with care” may be defined as local translators’ translation of innovative ideas in a way that tests the pros and cons of an idea in relation to local knowledge and takes appropriate steps to integrate those elements of the idea. The second section of the book is about “importance.” It examines how certain ideas are scaled up and selected and in some sense become more important than others, in a careful balancing of variation and selection, or exploration and exploitation. Lars Fuglsang explores some of the tensions between variation and selection in the context of public innovation. Through a case study of the Danish public library, he tries to build an analytical framework for analyz- ing innovation with care in the public sector. He shows how the mode of innovation is partly changing from “institutional innovation” to “open innovation.” This leads to a quest for mechanisms of variation and selec- tion, rather than, for example, mechanisms of homogenization among public institutions. Fuglsang argues that new social and strategic arenas are created in the library case, which enables variation and selection, and the diffusion of important new ideas. Gestur Hovgaard examines tensions that exist between exploration and exploitation, as well as stability and change, in the construction of an inno- vative new company, which is the Danish food-ingredient company Danmark Protein (DP). Today it is incorporated within the dairy giant Arla Innovation. Hovgaard shows how exploration and exploitation are activities that vary, due to different modes of innovation. This is a similar argument to Innovation with care 17
- 39. the one made by Fuglsang in his chapter. Finding a proper balance between exploration and exploitation is a key to the success of a company. This requires an “interpretative tradition,” mutual networking and a common understanding. This is consistent with both Sundbo and Fuglsang in this volume. Lars Fuglsang, Jeppe Højland and John Storm Pedersen applies a quan- titative analysis to investigate tensions between variation and selection again in the public sector. They present a survey, which has been sent to leaders in Danish public institutions about innovation activities. The chapter seeks to define a proxy for innovation with care in order to quan- tify its impact on various output measures. The survey shows that inno- vation does take place in the public sector, and that variation rather than copying is the rule. This is consistent with Møller’s findings (see below). The chapter also documents that innovation with care is an effective way of dealing with external requirements. Jørn Kjølseth Møller examines tensions between path-dependency and diversity in the public sector with a special view to a “Management Greenhouse”created by employers and employees’organizations in Danish municipalities. He argues that diversity in the public sector is a more common phenomenon than normally understood in, for example, neo- institutional theories. He shows how the potential for innovative manage- ment in public organizations is determined by the institutional context, where the public institutions are functioning. Similarly to Hansen and Serin (see below) and Fuglsang (the arena approach) he argues that these issues are incorporated into strategic arenas, where specific types of inter- ests are expressed, specific issues negotiated and specific rules of the game established. The Management Greenhouse is an example of this. In the third section of the book, three chapters discuss how actors can position themselves in various ways in the broader, macro-economic context of innovation – and what tools are available for that. Povl A. Hansen and Göran Serin investigate tensions between universi- ties and firms and different notions of public and private research. By way of a case study of Øresund Science Region they argue that a “platform organ- ization” can be seen as a solution to these tensions when universities and firms have different perspectives on the purpose and structure of research. According to Hansen and Serin, a platform organization can promote a caring approach among the different institutions to each other’s approaches. Hansen and Serin use the so-called triple helix model of government- university-industry interaction to explain the role of the platform organiza- tion as a framework for interaction and positioning. Ada Scupola and Charles Steinfield explore the tensions that exist between firms’ globalization and localization perspectives, and how these 18 Introduction
- 40. differing perspectives can be “taken care of”. Through a case study of Medicon Valley, a leading biotechnology cluster in Denmark, they show how Internet-based technologies and a number of additional critical activi- ties can contribute to and support the development of localized economies such as industrial clusters, while also contributing to the globalization of the economy by connecting companies and clusters of companies across different regions of the world. Jerome Davies and Lee N. Davies examine tensions between an individ- ual inventor (the “Mad Max”) and the commercial context in which that inventor has to position himself. The chapter refers to a case study of inven- tor Robert Kearns and his lawsuit against the American and European automobile industry. Davies and Davies argue that many inventions may not have any commercial potential to begin with, irrespective of what the “mad” inventor may have thought. Although inventors are “ripped off,” this may be more a reflection of their lack of positioning skills than of any major wrong-doing on the part of their financial partners. Those inventors who have been “ripped off,” as was the case with Kearns, might have avoided this fate by observing the signals of their opposite number more “carefully.” In the final section of the book about “sensemaking,” four chapters examine tensions and paradoxes at the micro-level that are critical to benefiting from innovation. Peter Hagedorn-Rasmussen analyses tensions between strategy and sensemaking by way of a case-study of a e-realtor company under creation. “Care” describes, according to Hagedorn-Rasmussen, an approach that bridge the relationship between the seemingly uneasy pairs of strategy and sensemaking. Care implies a very broad range of meanings including assiduousness, thoughtfulness, sensitivity, consideration but also anxiety, trouble and concern. It might be argued that this lack of conceptual accu- racy makes it an odd concept in (micro)sociological studies. On the other hand, the connotations we attribute to the concept of care may be highly accurate and descriptive for the processes of innovation as well as entre- preneurship, where the balance between strategy/strategizing and sense- making is important. Connie Svabo explores tensions between innovation and durability in an innovation project in the fashion industry. She argues that an innovation, paradoxically, is an artifact, which is continuously engineered and main- tained in a stable form. She presents a case study (or story) of an innova- tive project, “Sidecar” in a small-scale fashion industry, which was both a success and a failure. In line with the approach presented by Scheuer, Svabo focuses on actor-network theory and translation. The chapter tells a story of the struggles of translating innovative ideas into material forms, and Innovation with care 19
- 41. shows that the work of innovation consists of continuous attempts to create material order. Hanne Westh Nicolajsen examines tension between a new networked communication technology, called ProjectWeb, and three organizational settings in which it is implemented. Her study demonstrates the critical role of the individual entrepreneurs (or “intrapreneur”) as an integrating force of technology, innovation and organizational change. According to her study, entrepreneurs are not only needed in the initial phase of idea gener- ation, but also in the phase of implementation. Hanne Westh Nicolajsen argues that it is extremely important to make sure that at least one central person have the right qualifications and interests in order to benefit from technological changes and innovations in an organization. Finally, Poul Bitsch Olsen, inspired by the approach of Karl Weick, analyses a tension in innovation projects between old and new experiences. His example comes from sports: the continuous innovation that goes between a handball league coach and his team. Olsen shows how the experi- ence of interruptions and change processes must be continuously made intelligible and selected at the micro level. He argues that “mindfulness” or “mindful innovation” is a concept that can be used to understand how cre- ative action and new experiences are carefully selected and used in this way. Mindfulness in innovation means that experience is noticed and made intel- ligible, and new knowledge is the outcome of this. REFERENCES Amabile, T.M. (1996), Creativity in Context: Update to The Social Psychology of Creativity, Boulder, CO: Westview Press. Amabile, T.M., R. Conti, H. Coon, J. Lazenby and M. Herron (1996), “Assessing the work environment for creativity,” Academy of Management Journal, 39 (5), 1154–84. Chesbrough, H.W. (2003), Open Innovation: The New Imperative for Creating and Profiting from Technology, Boston, MA: Harvard Business School Press. Csikszentmihalyi, M. (1996), Creativity: Flow and the Psychology of Discovery and Invention, New York: HarperCollins. Daft, R.L. and K.E. Weick (1984), “Toward a model of organizations as interpre- tation systems,” Academy of Management Review, 9 (2), 284–95. Ellison, N., Ch. Steinfield and C. Lampe (2006), “Spatially bounded online social networks and social capital: the role of facebook”, paper read at The Annual Conference of the International Communication Association (ICA), 19-23 June, at Dresden, Germany. Fuglsang, L. and J. Sundbo (2005), “The organizational innovation system: three modes,” Journal of Change Management, 5 (3), 329–44. March, J.G. (1991), “Exploration and exploitation in organizational learning,” Organization Science, 2 (1), 71–87. 20 Introduction
- 42. Mulgan, G. and D. Albury (2003), Innovation in the Public Sector, London: Strategy Unit, Cabinet Office. Nelson, R.R. and S.G. Winter (1977), “In search of useful theory of innovation,” Research Policy, 6 (1), 36–76. Nowotny, H., P. Scott and M. Gibbons (2001), Re-thinking Science: Knowledge and the Public in an Age of Uncertainty, Cambridge: Polity Press. Parker, S. and J. Heapy (2006), The Journey to the Interface, London: Demos. Phillips, A. (1971), Technology and Market Structure: A Study of the Aircraft Industry, Lexington, MA: Lexington Books. Popper, K.R. Sir (1962), The Open Society and its Enemies, London: Routledge & Kegan Paul. Rogers, E. (1995), Diffusion of Innovations, New York: Free Press. Schumpeter, J.A. (1934, 1969), The Theory of Economic Development, Oxford: Oxford University Press. Schumpeter, J.A. (1947), Capitalism, Socialism, and Democracy, London: Allen & Unwin. Sundbo, J. (1998), The Organisation of Innovation in Services, Frederiksberg: Roskilde University Press. Sundbo, J. and L. Fuglsang (eds) (2002), Innovation as Strategic Reflexivity, London: Routledge. Surowiecki, J. (2004), The Wisdom of Crowds: Why the Many are Smarter than the Few and how Collective Wisdom Shapes Business, Economics, Societies, and Nations, London: Little Brown. Weick, K.E. (1995), Sensemaking in Organizations, Foundations for Organizational Science, Thousand Oaks, CA: Sage. Young Foundation (2006), Social Silicon Valleys: A Manifesto for Social Innovation, What it is, Why it Matters and How it can be Accelerated, London: Young Foundation. Innovation with care 21
- 46. 2. Innovation and involvement in services Jon Sundbo INTRODUCTION This chapter will discuss innovation in services and employees’ and man- agers’involvement in the innovation process, which means that the top man- agement takes care of employees and managers. Service is a production which requires the involvement of employees and managers in the innova- tion process because it is what could be called a “broad” organizational process. By this I mean that it is a process that involves the total organization and not only a small group of researchers. Involvement in service innova- tions is not an advantage, it is a must. Care, which means awareness of the employees’ wellbeing and behavior and attempts to improve these, is, there- fore, a prerequisite for service production. “Service” is a broad category (see Illeris, 1996, for a definition) which is generally defined as the solving of problems that cannot be solved by the customer himself by use of a tool, a commodity. Services includes physical services such as cleaning, transport, operating hotels, knowledge services (for example education, consultancy, banks, real estate agency and per- sonal services), health care services (for example hospitals), social services (for example social security and advice), psychotherapy and hairdressing to name but a few. In the chapter I will, on the basis of earlier empirical studies, discuss theo- retically how the innovation process in services can be conceived. First I will discuss the nature of innovation in services and present an overview of the literature on innovation in services. Then a model of the innovation process is introduced and it is discussed how care is a part of the process. Finally, I will provide three empirical examples to give a deeper understanding of how innovation with care is carried out. 25
- 47. INNOVATION IN SERVICES What are innovations in services? I will start by discussing the nature of service innovation. There is a general overview of the literature on innova- tion in services which summarizes the research results and the general inter- pretation of what innovation in services is (Miles, 2004; Aa and Elfring, 2002; Gallouj, 2002; Sundbo, 1997, 1998; Boden and Miles, 2000; Coombs, 1999). The character of service innovations is discussed in this literature. A core element in the discussion has been whether innovation in services is different from that in manufacturing. The basis for this discussion are the many case studies that have been carried out about services firms (for example Miozzo and Soete, 2001; Sundbo, 1996, 1998; Boden and Miles, 2000; Howells, 2004; Vermeulen, 2001; Metcalfe and Miles, 2000; Andersen et al., 2000; Sundbo et al., 2001; Fuglsang, 2002; Gallouj, 2002; Brentani, 1993; Finch et al., 1994). These case studies have been carried out in a variety of service industries (for example consultancy (van Poucke, 2004; Sundbo, 1998), engineering consultancy (Mattsson, 1994; Larsen, 2001; SIC, 1999), computer services (Jönsson, 1995), cleaning and other opera- tional services (Djellal, 2002; Sundbo, 1999a) and tourism (Hjalager, 2002; Mattsson et al., 2005; Sundbo et al., 2007)). Surveys also play an important role. The well-known CIS-surveys (Community Innovation Survey) carried out by Eurostat (Innovation in Europe, 2004; Evangelista and Sirelli, 1998; den Hertog et al., 2006; Drejer, 2004) have, since the early 1990s, included services. Other European surveys have also been carried out (INNO- Studies, 2004; Hipp and Grupp, 2005; Djellal and Gallouj, 2001; in Denmark SIC, 1999; Erhvervsministeriet, 2000). It has been demonstrated that innovations in services are more complex and integrated. Namely, they are often product, process, organizational and market innovation in one and they are often small improvements (Voss et al., 1992; Boden and Miles, 2000). Innovations in services are rarely radical or large-scale (see Sundbo, 1998; Gallouj, 2002), but are mostly small improvements of products and procedures. Services are the delivery of a complex process in which the service is marketed contemporaneously with its production. Service innovations may be of different kinds. They may be product innovations (a new service product), process innovations (new procedures for produc- ing the service), delivery innovations (new ways of delivering the service including peripheral service (see Normann, 1991)) and quality assurance (see Edvardsson et al., 2000); market innovations (new behavior on the market or new strategic alliances), or organizational innovations (new organizational forms, for example new structures or a new organizational culture. 26 Involvement
- 48. A service is fundamentally a behavioral act, and innovation in services a renewal of human behavior. This behavior often implies the use of tech- nology, but the act is essential, which is why care is so important. This is also the reason why it is a service and not a need that can be satisfied by the customer buying a commodity. The service must be produced and deliv- ered by a person at the moment of consumption. There are innovations in service technology; for example knowledge services (such as accountancy, consultancy, education) use IT and many services (for example insurance, banking) cannot be carried out without the use of IT to administer the service. All in all, innovations in services are both behavioral and tech- nological, however, they are more behavioral than in manufacturing. Empirical investigations have shown that 16 percent of the innovations are technological and 30 percent depending on technology, and 54 percent of innovations are non-technological (Sundbo, 1998). Service innovations have increasingly become technological, particularly in knowledge services where the service can be delivered as a self service via IT-networks (the Internet, mobile telephones and so on). Thus, when we talk about service innovations, we may be talking of both technological and behavioral inno- vations and often a mixture of both. Service innovations are often integrated, which means that they are product, process, organizational, delivery and market renewals at the same time. Even though they are integrated, they are often only small steps in renewing the services. Examples of typical service innovations could be a new insurance policy with different conditions and premiums; a cleaning contract not defined by the procedures but by the result (whether the cus- tomer is satisfied that things are clean), a new way of measuring employee satisfaction presented by a management consultancy, a hotel introducing free fruit in the reception. One may even discuss whether such small changes are innovations (see Sundbo and Gallouj, 2000). However, they develop the service firms and create economic growth. An attempt to create a distinction between innovation and the daily changes that everything goes through has been to argue that for something to be an innovation the change must be reproduced (Sundbo, 1997; Gallouj, 2002). The new service for a customer must be repeated for other customers, the new procedure or organization for producing and delivering the service must be widespread in the firm and so on. Service innovations have also, in one tradition, been conceptualized as service development and seen as new solutions developed on the basis of the observation of service quality problems (Edvardsson et al., 2000). Service innovation is described as service design and the tradition is ori- ented towards practical solutions (for example Gummesson, 1991). Thus, service innovations in this tradition are seen as a result of a kind of service Innovation and involvement in services 27
- 49. engineering where new services are constructed, often with the aim of improving the service quality. THE ORGANIZATION OF INNOVATION Innovations in services are mostly behavioral. Thus, they are different from the mainstream product innovations in manufacturing, which are techno- logical. However, there are similarities. Some service innovations are tech- nological and some innovations in manufacturing are behavioral. But what about the innovation process – the way in which the work with innovation is organized? Is that different from what we know from the mainstream lit- erature, which is based on manufacturing? The nature of the innovation process in services will be discussed in this section. Innovations in services are not laboratory or science based (Sundbo, 1997; Gallouj, 2002) as they typically are in manufacturing. Often inno- vations are ad hoc, based on ideas from employees or managers. They may be part of a more systematic process, however the innovations are not top-down dictates, but must be developed along the way when ideas occur. Even when the organization attempts to have a very systematic innovation process, the concrete innovations must be developed by employees in the organization. This situation in particular requires that many employees and managers are not only involved in the innovation process, but also that they feel involved. Innovation in services is extremely dependent on the employ- ees’ and managers’ commitment to innovation and care. This also applies to the top manager, who should be open to the active involvement of the employees. Customers also play a central role in service firms’ innovation processes. The philosophy of service production is – according to the service man- agement and marketing theory (van Looy et al., 1998; Grönroos, 2000) – based on the customer as a co-producer. All this means that innovation in services is a process which greatly involves different actors. It is not left to experts as is often the case in manufacturing where scientists make most of the effort. Innovation has been described as a dual process that is both top-down and bottom-up (Sundbo, 1996). The employees and middle managers get ideas about new service products or new ways of producing and delivering the services and fight for realizing their ideas. Such processes appear natur- ally in all organizations. Often they die because the top management do not react to the ideas or even reject them and signal negative sanctions towards employees who use their time to get ideas and argue for them. This is not an optimal situation for the top management since innovations do not 28 Involvement
- 50. surface in such an atmosphere, or at least fewer do. The top management is rarely able to produce all the necessary ideas themselves and they do not normally have an expert apparatus with the particular task of producing innovations. The top management therefore becomes dependent on the employees presenting ideas and thus on a care system. However, the number and type of ideas should also be limited, if not, the organization can waste many resources on getting ideas and communicat- ing about their realization. The top management therefore continuously makes decisions concerning which ideas should be realized and which should be rejected. This places the top management in a power position, but it also forces the top manager(s) to be involved in the innovation processes. Innovations often come from the top. The top managers get ideas or set up a framework for innovation activities. However, the top manager cannot develop and implement the innovations himself. He needs the employees in that process. Whatever the idea presented by the top manager or an employee, it leads to other employees and managers being involved in the process when the innovation is to be employed. A service is a behavioral activity that involves many people. Finally, the new service must be deliv- ered by some service personnel. A service is not a commodity that can be produced by a machine and stored. It is an activity that must be produced by people at the moment of consumption and often the customer must be present. All this leads to the fact that innovation in services is a process that naturally involves many people and if the process is to be successful, all these people must feel involved and cooperate, which means care. The development and implementation of innovations is normally organ- ized as project work. If the management decides to continue with the idea, a project group representing different departments and often including the idea-maker is established. The project group develops the idea to a proto- type that is taken over by the department which will produce the new service or implement the procedure. To have a successful development and implementation process requires that all these people feel involved. The customers have a particular position in service production as men- tioned. This is also the case concerning innovation. The service personnel pay much attention to the customers and how they perceive the service. This is both related to observing possible quality problems, how the service works for the customer – whether it solves his problem – and if he will buy the same or other services from this firm again. This service-attention also implies that employees often find a better solution for an individual cus- tomer; for example, a better procedure for cleaning or a more convenient type of pension saving. This better solution could be new and should then be diffused to other service workers in the firm (reproduced) and thus Innovation and involvement in services 29
- 51. become an innovation. Often the service employee observes that the cus- tomer has an unsolved problem which could be solved by a new service. This is also the basis for an innovation if the employee presents it as such in the service firm. Innovation in services is often customer based and customers are involved in the innovation process (for example Howells, 2004). This does not mean that the innovations are customer determined. The customers do not directly present ideas for innovations. Service firms that have tried to involve customers in this way have had bad experiences. Customers are rarely able to tell which new services they want in the future. Customer involvement is via interaction with employees, who then develop ideas for innovations. When the top management wants to involve customers in the innovation process, which is a good idea, it must nurse the employees’ meeting with the customers (the “moment of truth” in service production, (Carlzon, 1987). Here there is a particular emphasis on the employees getting innovative ideas from this meeting. The customers again play a role in the later stage of the innovation process where a prototype of the inno- vation must be tested. The prototype is tested on customer groups, either in the form of discussions in focus groups or on a limited market segment. Because innovations in services often are behavioral, there is normally no R&D or other expert department which carries it out, and the service firms are dependent on the employees involving themselves in the process. It is therefore difficult to set up an ideal model concerning how the innovation process should be organized. Improvements in innovation ability becomes a matter of organizational learning (Argyris and Schön, 1978; Nonaka and Takeuchi, 1995). Managers and employees learn how to organize the inno- vation process from earlier cases and from other firms. The continuous learning process also requires care and involvement of the employees. These have the experience of what went well and what went wrong and they are those who will put the new forms of behavior into prac- tice. Thus the management is dependent on their involvement in the improvement of the capability to innovate. The management itself, includ- ing the top management, must also be involved in the learning process, if not, this will not be taken seriously by the employees. Entrepreneurship defined as establishing new firms on the basis of an innovation has not received much attention in relation to services. Only a few analyses can be found (for example Sundbo, 1998, and Morrison et al., 1999 in tourism). However, most new firms are within services, however, these firms are very often not innovative and not growth-oriented. Nevertheless, entrepreneurship does count for an important part of service innovations. In manufacturing it has been observed that innovation systems exist (Nelson, 1993). These are coherent networks of collaborating firms and 30 Involvement
- 52. institutions. In services, there is rarely a coherent innovation system. Many actors and streams of knowledge inputs (service professional, technologi- cal, management philosophical, trends in society and so on) are involved, but they do not act as a coherent system (Sundbo and Gallouj, 2000). SYSTEMS OF INVOLVEMENT AND CARE I will now present a model of the innovation process based on the research referred to above. The model consists of an overall conceptual framework based on the concept of strategic reflexivity, which will first be introduced and a phased categorization of the innovation process. The model divides the innovation process into three phases, the idea phase, the development phase and the implementation phase. The conceptual framework, it is argued from a statement of care, is a natural approach in service innovations. The involvement of actors and how the innovation process can be con- sidered as care-taking is discussed. I have stated that involvement of actors is important. However, the question arises: who are the actors in service innovations? Three main actors can be identified, namely managers, employees and customers. They have different roles in the three phases. Service Innovation Processes and Care Care is central in service innovation processes because these processes are based on the broad involvement of many employees, managers and cus- tomers and not only on expert-based R&D and technology development. The innovation processes are complex social processes. Care means that the top management is aware of the innovative potential of managers, employ- ees and customers (and other external actors) and nurses these poten- tials, but also that it sets limits for intrapreneurship based on the strategy. Many service firms do this, and I will later give examples of how they do it, however, most service firms could improve their care for the innovation process. The care aspect can be expressed in a conceptual model, which will be explained in the next paragraph. A Concept for Careful Service Innovation – Strategic Reflexivity Innovations in service firms must be understood as careful and coherent processes based on strategy forming a guideline (strategic innovation see Sundbo, 2001). Even though innovations often come from loose ideas through intrapreneurship, most service firms, at least the successful ones, Innovation and involvement in services 31
- 53. have a general principle about which innovation to develop. A conceptual model for this principle, called strategic reflexivity, has been developed by Sundbo and Fuglsang (2002, 2006). This model will be explained in this section and related to actor involvement and care. Strategic reflexivity involves managers and employees actively, not only in the detailed inno- vation processes, but also in the more general strategy process. Strategic reflexivity is a general principle that may be found in all organizations no matter which sector or industry, but it is particularly central in service firms. The model sees the innovation processes in service firms as a broad coherent process. Innovation is about the future of the firm. The service firm is developed within a broad framework which relates to the goals for where this firm will be in the market in the future. These goals and the overall means for getting there are expressed in the strategy as explained earlier. The strategy is the general guiding principle for the development of the firm. Most service firms introduce service concepts, which are broad service fields with a certain business idea. A service concept could, for example, be SAS’s business traveler’s airline in the 1980s where SAS wanted to serve the business traveler. This included high quality service counting peripheral ones such as admission to SAS hotels, thus the journey could be totally booked via SAS. The price was very high. Another concept in airline services is the more recent concept of discount flying that low-price airlines such as Ryan Air, and Easyjet have introduced. In that concept there is no extra or added services such as meals, hotels and so forth, and even the core service may be of poor quality (delayed planes and so on). However, the price is very low. Such broader concepts are not only a product, they are a bunch of products, processes, organizational forms, culture and attitudes. The strategy specifies in general terms which type of service concepts the firm should have. Innovations are the details that fulfill the concept. The concepts are defined by these details. Therefore innovations in services are small renewals which together change the concept. The strategy is an interpretation of the future market (see Mintzberg, 1994). As nobody can know the future market, the service firm can only provide a qualified guess and act on the basis of it. In the process of for- mulating the strategy, many service firms involve the employees and man- agers in order to have the broadest range of experiences, analyses and ideas. The top management makes the final decision concerning the strategy, but the employees and middle managers contribute to the process and can influence the strategy. When the strategy is decided, it must be implemented and work. The strategy defines the kind of service concepts (for example “are we a busi- ness travelers’ airline” or “discount airline”) and guides the innovation processes (define areas for possible innovations and the borders outside 32 Involvement
- 54. which innovative ideas can not be accepted). However, since the strategy is based on an interpretation of an unknown future, it is important to follow the market and general societal trends to see if the pre-assumptions and the implementation of the strategy is still valid. This requires involvement of employees and managers. They follow the market, among others through direct customer contact and they have a broad involvement in society. The employee and managers should, therefore, reflect on the strategy and whether it still works. Therefore the model is called strategic reflexivity. This reflexivity also includes considerations about whether the types of innovation and the concrete innovations are the right ones. All employees and managers should be potentially involved in these deliberations. Some have this as a working task, the others are to present their considerations if they discover a problem. Such problems may include that the strategy does not seem to work, the service concept does not seem to work or the inno- vations that have been implemented have not been sufficiently successful. The reflections may be based on systematic analyses and market investiga- tions, on knowledge about new technology or service principles that the firm has not considered or just on concrete daily observations. Changes may also come from employees or managers acting as intrapre- neurs by getting ideas for innovations and fighting for having them accepted. The new ideas may be within the framework of the strategy and thus the intrapreneurship is a contribution to an optimization of the stra- tegic goals through involvement. They may also break the strategic frame- work. In most such cases they will be rejected. However, in some cases reflections within the management or among the employees may lead to one innovative change of idea – not only the service concept, but the whole strategy. The reflections and innovative ideas and intrapreneurship thus may lead to an adjustment of the principles for which types of innovations should be developed, to the introduction of new types of service concepts or to an adjustment of the strategy. In rare cases it may even lead to the introduc- tion of a new strategy. These decisions are made by the top management, but the employees and middle managers are involved in the process through their reflexive roles. The strategic reflexive innovation mode also includes the creation of the different in the innovation processes that have been mentioned. These roles can be institutionalized. The management may be aware that there are people who play all the necessary roles and, if not, they can employ such people or encourage such behavior to be developed among the employees. This is a core part of care for the innovation process. Customers do have a central role in the model of strategic reflexivity, not as directly involved actors. They are the final judges that decide on strategic Innovation and involvement in services 33
- 55. Exploring the Variety of Random Documents with Different Content
- 56. of the mucous membrane lining the whole alimentary canal, is vitiated, as is proved by the unnatural quantity, colour, and fetor of the evacuations; the urine likewise is altered in appearance, and the skin is not more remarkable for the sense of heat, than for that of dryness and harshness which it communicates to the touch. With the excitement of the pulse and the increase of the heat, the pain in the back and limbs and the general febrile uneasiness are much augmented. At this period, then, the fever is fully formed; the series of morbid phenomena is complete: any thing more that happens is referrible to degree and to duration, and must be the result of one or other of these circumstances, or of their combined operation. And we now see that the organs affected, constitute precisely that system of organs which has been described as forming the febrile circle: that the symptoms which denote the fever are just the symptoms which indicate a derangement in the several functions performed by these organs; and that the order in which they become successively involved is exactly that which has been assigned. As soon as the preternatural heat comes on, pain begins to be felt in the head. Dr. Clutterbuck, in describing the general character of the ordinary fever of London states[23] that “the first symptom almost invariably complained of is more or less of uneasiness of the head.” If by uneasiness he meant pain, there is, if there be any truth in the preceding observations, a long train of symptoms to intervene before this symptom occurs. That it does ultimately occur is certain: but commonly its place in the series is much later than is here assigned: it is disordered function of the brain, indicated by loss of mental energy, that appears to form the first symptom in this morbid train. The pain, when it does come, is sometimes slight at first, and occasionally it remains slight throughout the disease; at other times it is pretty severe. Cases sometimes occur, in which, instead of pain, there is only a sense of giddiness, and now and then the uneasy feeling is described as that of lightness: or, on the contrary, as that of heaviness or weight. But whether the feeling be pain, and that pain be slight or severe, or whether it be giddiness, or lightness, or heaviness, it indicates a similar condition of the organ, and requires a similar treatment.
- 57. With the accession of pain of the head there is a manifest increase in the disturbance of the sensorial functions. The inability to think, to compare, to reason, to judge, great as it was at the commencement, is now much greater. Instead of being more dull, there are certain states of the mind which now become more acute and vigilant even than in health. Sensation itself, at this period, is invariably acuter than natural, as is indicated in all the organs of sense. The eye cannot well bear the light: there are few cases in which the full glare of day does not excite uneasiness, while in many the ordinary light of a room cannot be borne: in these cases the opening between the eye-lids is frequently observed to be contracted, as if from an involuntary effort to exclude a portion of that stimulus which in health excites no inconvenience, and this state of the eye- lids assists in giving to the eye its dull and heavy expression, so characteristic of fever. The increase of sensibility in the organ of hearing is equally striking. Sounds which were not noticed during health become acutely and even distressingly sensible, while accustomed noises, such as that of a crowded street, are always painful and often intolerable. The skin, considered as an organ of touch, is in a like morbid state. An impression barely sufficient in the state of health to produce sensation excites the feeling of tenderness, and alternations of temperature, which in ordinary states are scarcely perceptible, are painful. The senses of taste and smell, on the contrary, are nearly obliterated, owing to the altered condition of the membranes upon which the sensitive nerves are distributed. From the earliest attack of the disease the sleep is disturbed and unrefreshing; now scarcely any is obtained; the febrile uneasiness will not allow of repose; the patient cannot remain in any position long, incessantly shifting his place, never eluding his pain. At this stage the sense of uneasiness in the limbs, oftentimes the severity of the pain over the whole body, is peculiarly distressing. With this progressive increase in the affection of the spinal cord and the brain, the derangement in the circulating system is proportionally augmented. The pulse is invariably altered, both in frequency and character. Generally it rises to 90, sometimes to 100; but in this form of fever it seldom exceeds this number; and occasionally it never rises above 80. The stroke of the pulse is usually stronger and fuller than natural, though it commonly retains its
- 58. softness, and does not impress the finger with that sensation of sharpness which is characteristic of ordinary inflammation. Occasionally, however, a degree of sharpness may be perceived in it, and it is not easily compressed. The thin white fur which already had begun to appear on the tongue progressively increases in extent and thickness. The colour of the fur usually changes, as the disease advances, from a dirty-white to an ash-colour; but in this form of the disease the tongue always remains moist, and never becomes brown. This state of the tongue is almost always accompanied with thirst, but it is never urgent. There is always a loss of appetite. The bowels are generally constipated, and the secretions of the whole alimentary canal are vitiated. Thus we perceive that the progress of the disease consists in increasing mental and corporeal weakness; increasing pain in the back, loins, and limbs; increasing heat of skin, acceleration of pulse, and general febrile uneasiness, together with the occurrence of pain in the head, and progressive derangement in the functions of secretion and excretion. The fever in this mild form is now at its height. It remains stationary, or at least with very little change for an indefinite period, generally for some days. The cerebral affection does not increase beyond what has been described: there are no greater indications of disease in the respiratory organs, and the mucous membrane of the stomach and intestines does not denote any progressive advancement in disease. One of the most remarkable circumstances connected with the ordinary fever of this country, in the present day, is the uninterrupted and perfect continuity of its phenomena. As long as the febrile state remains, nothing deserving the name of a remission is in general to be perceived. Occasionally, it is true, a slight increase in the symptoms may be observed towards evening, especially in the heat of the skin; but even this is not common, and it is scarcely ever great enough to deserve the distinction of being called an exacerbation. Much less is there any regularity in the accession and decline of such excitement. In the great majority of cases not the slightest approach to an exacerbation and a remission can be distinguished from the commencement to the termination of the disease. Yet the older writers speak of these events as if they were as
- 59. palpable as the paroxysms of intermittent and as constant as the return of morning and evening. There cannot therefore be a doubt that the character of the ordinary fever of this metropolis is greatly changed from the character of that which prevailed two centuries ago; and the circumstances which have contributed to produce this change will be considered hereafter. In the great majority of patients in whom the symptoms continue thus moderate, the disease disappears about the end of the second week; that is, they are convalescent at that period; but it usually requires eight or ten days longer before they have regained sufficient strength to leave the hospital. Sometimes, although there is no greater severity in the symptoms, the disease is more protracted, and the recovery is not complete until the fourth or even the fifth week. Beyond this period it is very rare for this form of the disease to be protracted. Almost all who are attacked with the malady in this, its mildest form, recover: but now and then it happens that the symptoms go on with this degree of moderation until about the end of the second week. Then at the period when it is usual for convalescence to take place there is no perceptible improvement; the patients seem even to grow weaker; they lie more prostrate in the bed, and they are soon incapable of moving; still they complain of no pain or uneasiness, and it is not easy to detect any trace of disease in any organ; yet it is but too evident that they grow worse, and ultimately they sink exhausted. In these cases, on examination after death, it is commonly found that disease has been preying on some vital organs, although its presence could not be detected during life; and this termination of the milder type of fever rarely happens, excepting in aged persons, whose constitutions have been enfeebled by previous diseases, or worn out by the various causes which depress and exhaust the powers of life. With an occasional exception of this kind the disease in this form always terminates favourably; and the first indication of returning health is remarkably uniform: it is almost always marked by longer and more tranquil sleep. Instead of that restlessness which is so characteristic of fever, and which forms the most distressing part of it, the patient is observed to lie more still, and on waking for the first time from an undisturbed slumber, he often spontaneously says that
- 60. he feels better. Better he may well feel, for his febrile uneasiness is gone; the load that oppressed him is shaken off; he is a new being. The pain of the head and of the limbs is so much diminished that often he cannot help expressing his thankfulness at the change. The countenance becomes more animated; its natural expression returns; the tongue begins to clean; and after this state of the system has continued for two or three days, the appetite returns. While these favourable changes are going on, the pulse usually sinks about ten beats below its highest point at the height of the fever; it is not uncommon, however, for it to remain quick during the entire period of convalescence; and for some considerable time it is easily excited on any movement of the body, or any emotion of mind. In some cases, on the contrary, when the attack has been very mild, it sinks considerably below the natural standard, and is intermittent, a sign which I have uniformly observed to be attended with a sure and steady convalescence. In the mean time the appetite becomes keener than natural; the strength gradually improves; and in a short time the patient is restored to his usual health and vigour. What the condition of the brain and of the organs correlatively affected is, in these the mildest cases, we do not positively know, because we have no opportunity of inspecting them, their favourable termination being nearly without exception. But the more all the phenomena are considered in their entire series, in the order of their succession, in the uniformity, nay, even in the exclusiveness of their seat, as well as in the unchanging sameness of their effects, the more clear the evidence will appear of the soundness of the induction, that the condition of all the organs in all the types of fever is the same in nature, although there be no two cases of any type perfectly the same either in the degree of the affection or in the stage of the morbid process which it excites. If this induction be really just, we must conceive that, in the synochus mitior, while the morbid affection of the organs is slight, the diseased process which it sets up in them stops before it produces any change in their structure. However this may be, and to leave for the present all matter of inference, and to keep strictly to the matter of fact, we do positively know that the mild forms of fever become severe in consequence of the supervention of inflammation in certain organs. Perfectly unknown as the nature of the primitive febrile affection at present is,
- 61. yet that in the progress of the disease it does ultimately pass into inflammation is a fact, the evidence of which it is impossible to resist; although the same observation which teaches us this most important truth, teaches us also that the inflammatory action is always considerably modified by the febrile state. How it is so modified, and to what extent, we shall consider hereafter. I have spent much consideration and some labour in the effort to combine the symptoms which attend these severer forms of the disease with the ascertained conditions of the organs upon which such symptoms depend. But since it is of paramount importance that the events which actually take place should be known, and that the order in which they succeed each other should be stated with clearness and exactness; and since I have been able by no method that I could think of to combine the pathology with the history without breaking too much the continuity of the latter, I have been under the necessity of separating these two most intimately connected subjects, and of treating of them under distinct sections. In giving the history of the events, I have detailed them strictly, as far as I am acquainted with them, in the order in which they occur: and I have endeavoured to arrange the cases that constitute the pathology in such a manner, that they shall closely correspond to these events, and clearly illustrate the order of their succession. If I have succeeded according to my wish, the reader in studying the cases will be reminded, as he proceeds, of the successive stages of the history, and if he again revert to the history, after having studied the pathology, he will be reminded of the morbid appearances in the organs which are there described. To afford a clear perception of the connexion between the successive events, as indicated by the symptoms during life, and the progressive changes of structure in various organs, as demonstrated by inspection after death; and thus to establish a strong and indissoluble association in the mind between the morbid condition and its sign, are the objects at which I have aimed. If I have succeeded, I shall have accomplished one of the chief objects of my undertaking. The transition of a mild case of fever into a severe one, or the progress of a case severe from the commencement, is accompanied with, or depends upon, as will abundantly appear hereafter, certain changes that take place in certain organs. These changes occur with great regularity; the organs in which they take place are always the
- 62. same; and the symptoms by which they are denoted are uniform. The organs affected are the spinal cord, the brain, the membranes of both, the mucous membrane of the lungs, and the mucous membrane of the intestines. For the reason just assigned the nature of these affections cannot be described in this place, but must be postponed to that part of the work which treats of the pathology. Since however the symptoms are nothing but the signs of these conditions, and the history of the succession of the former, is nothing but an account of the indications of the successive changes that take place in the latter, all the important symptoms must necessarily have their seat in the head, in the thorax, and in the abdomen. Mixed and blended as they appear in the different cases which the practitioner is called upon to treat, nothing can appear more complex or more variable: when analyzed, nothing is more remarkable than their simplicity and their uniformity. In order to perform that analysis with exactness, and to render it really instructive, these symptoms must be contemplated as they arise in the affected organs. These organs, as we have seen, are the cerebral, the thoracic, and the abdominal; the symptoms therefore divide themselves into cerebral, thoracic, and abdominal: there is, indeed, a fourth order, in which all the organs appear to be equally involved; in which the general affection is intense, and which therefore may be appropriately termed mixed. We shall see that cases of this kind constitute by far the most dangerous form of the disease.
- 63. I. Synochus Gravior with Cerebral Affection, occurs under two degrees of intensity: when the cerebral affection is moderate, it may be termed subacute; when great, acute. 1. Synochus with Subacute Cerebral Affection, may be attended for several days with no symptom which has not been already enumerated in the account of the mildest form of the disease. The accession is the same as in synochus mitior: the progress up to a certain period is also the same. But at the time when the pain of the head diminishes in the latter, it increases in the former. Still the pain is often not severe. He who looks for intense pain, and suspects no cerebral affection, unless accompanied with this symptom, will be surprised by what will appear to him the sudden occurrence of new symptoms, such as are immediately to be stated, which will at length open his eyes to the danger of the case, and excite his wonder, which it is not unfrequent to hear expressed, that an affection hitherto so mild, should, without any previous warning, become so formidable, and show but too manifestly that it is beyond control, and will certainly proceed to a fatal termination. The warning was given, but the sign was not understood. The descriptions of disease are commonly taken from its most acute form; and it was long the practice to derive them from this form alone, and the consequences were truly fatal. Even with the best care that can be taken in drawing up the history, these descriptions are exceedingly apt to become ideal, and not real entities: to consist of a collection of all the circumstances that exist in all cases, and not of that particular combination only which is found in any one case: and thus to be not the portrait of any individual, but a fancy picture bearing a general resemblance to all individuals without being the true likeness of any. The consequence is, that at the bed-side of the sick the original from which the picture is supposed to be taken is not to be seen, and the practitioner remains in doubt, if he do not fall into error. Error serious and fatal many have fallen into, and, on this very account, still continue to fall into, with regard to the existence of cerebral
- 64. disease in fever. Abundant evidence will be given in the pathology, that it is not uncommon for the most unequivocal and extensive changes of structure to take place in the brain and its membranes without severe pain having ever been felt. Pain, however, though it be not great, is almost always present. It is seldom that the pain extends over the whole head; the patient generally points to some particular part where it is peculiarly felt. In the majority of cases the seat of the pain is either in the forehead, or at the temples, or over the eyes; but occasionally it is in the occiput, and extends down the neck, and in these instances it is often severe between the shoulders. Now and then no pain whatever is felt. Question the patient as much as you please, and he will tell you that he never has felt any pain. In this case giddiness is the substitute. Giddiness in the commencement, and in the early stage of fever, is as certain a sign of cerebral affection as pain. Striking illustrations of this are afforded by several cases detailed in the pathology; by consulting which, the reader will see that precisely the same morbid changes take place in the structure of the brain, although nothing but giddiness be complained of, as occur in those which are attended with the acutest pain. The practitioner will therefore fall into a fatal error who is seduced into security because pain is absent; and who neglects the remedies proper for inflammation of the brain, because the patient complains only of giddiness. If giddiness be combined with pain, or alternate with it, which is not uncommon, the giddiness being slight if the pain be severe, and the pain being slight if the giddiness be distressing, it indicates a more severe affection than if either exist alone. 2. In the majority of cases, as long as the pain continues, the heat of the skin remains considerably above the natural standard. But often the heat over the general surface of the body is not great. Commonly, however, it is hotter than natural over the head, and it is hottest wherever the seat of the pain be fixed: so that the contrast is often striking between the temperature over the forehead or at the occiput, and the heat of the body in general. 3. The dull and heavy expression of the eye is greater than in the milder form of fever. The conjunctiva generally becomes brighter and more glistening than natural: though instead of this the vessels are often more numerous and more turgid than usual, and give it the
- 65. appearance which is termed “muddled.” The eye at the same time is commonly preternaturally sensible, and cannot bear a strong light, although sometimes no complaint is made if the curtains of the bed be withdrawn, or the window-blind be drawn up. 4. There is usually a corresponding increase in the general sensibility; and what is remarkable, this is quite as much indicated by the increased sensibility to sound as to light. A loud noise is invariably distressing to the patient, and a continuance of it greatly aggravates all the symptoms. Exposure to a glare of light and a loud noise, would alone rapidly change a slight into the severest cerebral affection. The expression of the countenance is now very peculiar: it cannot be described, but the experienced eye can seldom fail to recognize it. It is indicative of suffering without the strength to bear it: it is not anxious; that expression does not come on until a later period. The face is sometimes flushed, but it is often pallid, which does but add to the peculiar character of its expression. 5. As long as the pain of the head, the giddiness, and the increased sensibility continue, there is invariably a want of sleep. The degree of sleeplessness is not always in proportion to the head-ache or to the other symptoms; but while the latter are present, the former is never absent. That condition of the brain upon which sleep depends appears to be easily disturbed by a great variety of causes; but whatever be capable of affrighting this heavenly visitant, “tired Nature’s sweet restorer,” whether in the mansion, the palace, or the prison, and whether from the bed of healthful slumber or from the couch of sickness, nothing so effectually and so constantly banishes it as that febrile uneasiness of which we have already spoken; and which, instead of declining, as in the milder form of fever, now increases in strength and activity, and will scarcely allow the restless body to remain in one position for a moment. He who has felt its influence in this stage and degree of fever, will admit that there is nothing comparable to the wretchedness it produces, except it be the sweetness of the first waking moment after the first tranquil slumber of returning health. 6. And now, sometimes closing this train of symptoms, but more frequently being the first harbinger of another, delirium appears. Delirium is usually first observed when any slight sound rouses the
- 66. patient from that disturbed slumber which is the only substitute allowed for sleep. The delirium is seldom violent or long-continued, but, when present, is like the talking of a person during sleep in a disturbed dream. This symptom, however, is by no means invariably present, and when it does come, it often postpones its visit to a somewhat later period. 7. The pulse, during all this time, may not be much quicker than in the mild form; and the state of the tongue and of the evacuations does not materially differ. Such is the train of symptoms when the brain becomes prominently affected. These symptoms continue without intermission, and with little change, for several days. The period of their duration, when only in this degree of violence, is commonly from eight to ten days: when their character is still milder or more subacute, or when they have been mitigated by appropriate remedies, it may be protracted fifteen days. About this period a remarkable change takes place; an entirely new train of symptoms supervenes, which is different, and which, indeed, presents a striking contrast, according as the patient is destined for life or death. If it be for life, that sleep, of the long absence of which we have already spoken, returns; and nothing can more truly express its character than its familiar name, “balmy;” and healing is its influence. From two or three hours of such slumber, the patient awakens a new being. Not that the change is at first striking to an inexperienced eye; but there is no fever nurse who does not recognize it in a moment, and it is not long before the patient tells you that he feels it. The febrile uneasiness is now much diminished: the headache is greatly relieved; and the skin is cooler and softer. The pulse may not yet be altered, or it may be a few beats slower than before, but there is almost always already an improved appearance in the tongue, which shews a beginning disposition to clean. These favourable changes gradually increase. If the sleep the next night be longer and more refreshing, which it generally is, on the following morning a decided improvement is visible in the countenance. The eye is clearer and more lively, and the expression of the countenance is more natural. The skin continues cooler and softer; the tongue is still cleaner, and the pulse, perhaps, slower by a beat or two; and
- 67. from this period, if no untoward event happen, the convalescence proceeds just as has been described in the return of health in the milder form of fever. If, on the contrary, the case proceed unfavourably, a totally new train of symptoms at this period sets in. 1. In the first place, the pain of the head obviously, and sometimes strikingly, diminishes. Often it disappears altogether, or, if any uneasiness remain, it is rather a sense of dullness and heaviness than pain. In like manner the giddiness, if that were urgent, is no longer perceptible: but it is remarkable that the pain in the back and loins not unfrequently continues for some time after the headache has disappeared: but, ultimately, that also ceases. The period at which this important change takes place depends upon the severity of the attack, and is materially influenced by the activity or inertness of the treatment. In the subacute form, it usually takes place about the tenth day from the commencement of the disease. 2. Simultaneously with the disappearance of the head-ache, there is a remarkable diminution of the sensibility. The mind is duller and more heavy. The patient may still be roused to answer with tolerable coherence if spoken to; but when left to himself he is confused and stupid. The eyes now become injected: often suffused; and the heaviness and dullness of their expression is increased. 3. It is at this time that delirium, if it appear at all, most commonly comes on. The increasing insensibility, if not attended with decided delirium, is almost always accompanied with moaning or incoherent muttering, especially during the short and interrupted slumbers which form the substitute for sleep. 4. Striking as these changes are in the functions of the spinal cord and brain, those which take place in the number and character of the pulse are no less important. Even in cases the most decidedly subacute, it is seldom that it does not rise ten beats, so that if before it were 90, it will now be 100, and it is always weaker. 5. Now, too, signs of disease in the chest and abdomen are almost always to be distinguished. A case purely cerebral, from the commencement to the termination of the disease, is rarely to be met with. If there be not cough, there is almost always a short and hurried respiration, and more or fewer of the indications of
- 68. abdominal affection hereafter to be stated. Even in cases the most purely cerebral the tongue always becomes more loaded and often dry; and it is strikingly characteristic of the state of the nervous system, that while the tongue becomes dry, the thirst diminishes. Thus far it is possible that the disease may proceed towards a fatal termination without proving mortal. It is not often that its course is turned back or stayed after it has made this progress; but still such an event is sometimes witnessed. When it does occur, the amendment, both in its origin and progress, is very similar to that of the favourable change which has already been described. More tranquil and longer-continued sleep is almost always the earliest sign that, in this severe struggle, life has obtained the victory. If, on awaking from such sleep, there be less delirium, were delirium present, or greater tranquillity, were the restlessness urgent; and if there be any increase, although slight, in the sensibility, or any improvement in the expression of the countenance, hope may be entertained that that victory will be won; and hope may become assurance, if the tongue which had been loaded become clean at the edges, or the dry tongue become moist. Even under apparently the most desperate circumstances, if these three symptoms concur, a favourable prognosis may be pronounced with tolerable certainty. Two or three days may elapse after their occurrence, before any remarkable change is observable in the pulse; but it is seldom that they continue twenty-four hours before the pulse falls at least ten beats. Now and then, on leaving a patient in the evening with a pulse at 120, we are surprised and delighted to find it in the morning as low as 100. When the pulse has thus fallen towards the natural standard, when the tongue has begun to clean, and when the skin has become cool and soft, however desperate his condition but a few days before, the patient may be said to be convalescent. But though this favourable change is sometimes witnessed, yet, from the point at which we left off the description of the progress to a fatal termination, the too common history is, increasing restlessness and sleeplessness; insensibility lapsing into coma; further acceleration of the pulse; greater dryness of the tongue and decreasing strength, until, at length, the powers of life receiving less and less supply from the great systems in which they have their seat, become completely exhausted.
- 69. Those who have been placed in situations which have afforded them opportunities of witnessing much of the disease will, I trust, acknowledge that the account now given is an accurate narrative of the symptoms that occur, and of the order in which they succeed, in the great majority of cases. Upon what conditions of what organs they depend will be illustrated in the pathology. Sometimes to these, other trains of symptoms are added—namely, muscular tremor, frequent and sudden screaming; rolling of the head upon the pillow; constant tossing of the hands about; picking at the bed-clothes or other surrounding objects; partial paralysis of the upper eyelid, so that one or both of the eyes remain half or almost wholly closed; the ball of the eye unsteady or constantly rolling; the expression of the eye and countenance at one time wild and anxious, at another fatuous; squinting; the respiration now slow and laborious, now exceedingly rapid; the pulse either slow, full and regular, or slow and intermittent, or so quick that it cannot be counted, or these states succeeding each other or alternating with each other at short intervals; convulsions; involuntary and unconscious stools—all these symptoms are never found combined in any one case; but certain assemblages of them occur with some degree of constancy, and depend upon certain conditions of the brain and spinal cord. Since, however, the description of these conditions cannot be given here, the further account of the signs which denote them must be postponed until we treat of the pathology of the disease. 2. Synochus Gravior with Acute Cerebral Affection.—Such is the history of the synochus gravior with cerebral affection in its subacute form. When its attack is the most acute, the history is precisely the same, excepting that the symptoms are more severe, and their progress quicker. The head-ache is much more intense; the giddiness is more violent; the sensibility is excessive; the least noise is intolerable; the slightest motion either of the head or of the body aggravates all the symptoms; the eye is muddy, and very soon becomes injected, and is perfectly intolerant of light; the pain in the back, loins, and limbs, is nearly as great as it is in the head. The skin is intensely hot, and sometimes impresses the hand with the sense of pungency; but though every where thus hot and dry, its temperature is peculiarly great over the scalp, so that if the head be shaved, and
- 70. wet clothes applied, they are quite dry in a minute or two. The febrile uneasiness is excessive; the patient can scarcely remain a moment in the same posture, and he is wholly without sleep. The pulse at one time is strong, full, bounding, and not easily compressed, but even in this acute form it is almost always soft; at least it is very different from the hardness characteristic of an acute attack of pure phrenitis; at another time it is oppressed, the stroke giving an impression directly opposite to that produced by the free and bounding pulse. But one of the most remarkable modifications of the pulse, one that is characteristic of an exceedingly acute attack of cerebral disease, and one with the import of which it is of the highest consequence to the life of the patient that the practitioner should be perfectly acquainted the moment he meets with it, is the slow and intermitting pulse. Whenever, in the onset of fever, a patient is found with intense head-ache or intense pain in the back and loins, and a slow pulse, the physician ought to be greatly alarmed at the severity of the symptoms that are to follow, and if he do not take the most active measures to break the violence of the disease at this early period, it will be beyond all control in a day or two, and the patient will be dead before the fever is well formed in milder cases. The affection of the brain is sometimes so violent and sudden that the pulse is not only slow, but intermitting, and the respiration is suspirious. Frequent and deep sighing is not uncommon in severe cerebral cases, and it is highly characteristic of intense cerebral affection; but in such a violent attack as that of which we are now speaking, the suspirious breathing, even in the very commencement of the disease, is so great that it cannot be overlooked. This happened in the case of my friend Dr. Dill, whom I saw a few hours after the commencement of an attack of one of these intense forms of fever. I saw him in the afternoon at a public meeting. I met him an hour afterwards at his own apartment. He was still going about engaged in his ordinary occupations; but his countenance was pale as death; his eye was dull and heavy; his mind was confused, and as it seemed to him paralysed; he had other sensations, which were new to him, and which were most distressing; but he had no pain: at that time there was not the slightest pain either in his head or his back or loins: there was only that general and undefined uneasiness which gave to him sufficient warning of what was coming, as the slow and labouring pulse, coupled with the uneasy sensations of which he
- 71. complained, and the peculiar aspect of his countenance, afforded to me an abundant confirmation that his apprehensions were just. He was bled immediately to the extent of twenty ounces: the blood then drawn was not sizy: he passed a wretched night. I saw him early the following morning: he had now intense headache; his eye was already injected; his skin was not hot but burning; his respiration was suspirious; almost every breath was a sigh, and his pulse was still slower than on the preceding evening, and was now intermittent: blood being drawn to a large extent, the crassamentum was now buffed and cupped; but the detail of the progress of this instructive case must be postponed until we speak of the treatment of fever, because it is still more illustrative of the effects produced by the vigorous application of the appropriate remedies than of the peculiarity of the symptoms which usher in the attack. It may suffice for the present to observe that this case affords not only a striking example of the concurrence of these peculiar symptoms, but also a decisive proof that pain of the head is far from being the first symptom that occurs even in the most intense cerebral attack. In these acute forms of the disease, if the proper remedies be not vigorously employed, the pain ceases within the fourth day; it rarely extends beyond the fifth; the pain passes into insensibility; delirium comes on, sometimes so violent as to require restraint, but delirium is by no means an invariable concomitant of the other symptoms, even when these are the most violent: when it is present it is almost always rapidly followed by muscular tremors, and these by subsultus tendinum, which now and then usher in general convulsions; but this last event is rare, and I have never yet seen convulsions unaccompanied with a particular condition of the brain hereafter to be described. Sometimes the muscular tremors succeed immediately to the transition of the pain into insensibility, while the insensibility rapidly increases to stupor, and that to profound coma. The breathing is occasionally as stertorous as it is in apoplexy, but this is also rare, and when it does occur, is probably dependent on a peculiar condition of the brain hereafter to be pointed out. Together with these there is a concurrence of a greater or a lesser number of the symptoms enumerated at page 107, but the particular combinations that are found most usually to accompany particular conditions of the brain, it will be most instructive to state in connexion with the pathology.
- 72. In synochus with acute cerebral disease there is less indication of thoracic and abdominal affection than in the subacute form, because the intensity of the cerebral disease obscures the signs of derangement in the other organs; but the signs of their derangement are never absent, although they are less obtrusive, and they trace in indelible characters proofs of their activity in the ravages they commit upon their structures in which they have their seat. Such is the course of synochus under different degrees of violence. When it is combined with subacute cerebral affection, that course is usually terminated in from three to six weeks; when with acute cerebral affection, in from seven to ten days. As an illustration of each form of the disease, as it is commonly met with in practice, I subjoin the following cases. Case I. John Colebert, æt. 28, admitted into the Fever Hospital August 1, 1828. Attacked five days ago with chilliness, alternating with heat, pains of limbs, head-ache, and sense of weakness. At present complains of pain of head, with slight giddiness; pains of limbs, especially of back and lower extremities; skin moderately warm; tongue loaded with white fur; much thirst; three stools; respiration natural; no cough, no uneasiness in chest; no epigastric or abdominal tenderness on full pressure; pulse 96, soft. 6th. Skin natural; pain of head gone; pain of back and limbs continues; slept better; tongue more clean; three stools; pulse 102. 7th. Pain of head not returned; pain of limbs better; tongue still cleaning; three stools; pulse 96. 9th. Pain of limbs gone; tongue nearly clean; two stools; pulse 84. 10th. Convalescent. 13th. Dismissed cured. Case II. George Walker, aged 17. Admitted May 5th, 1828.
- 73. Six days ago seized with shivering, succeeded by heat, loss of strength, and pain of head. At present complains especially of head- ache; ardent thirst; no pain of chest; no cough; no pain of abdomen, back, or extremities; skin cool; face natural; tongue, except at the point, covered with a thick dirty fur; much thirst; no appetite; sleeps badly; bowels costive, having had no stool for the last three days; pulse 98, of good strength. 7th. Heat of skin nearly natural; pain of head almost gone; no pain of limbs; tongue still much loaded; some thirst; three stools; pulse 72; slept much better. 8th. Tongue much less loaded; less thirst; five stools; pulse 60. 11th. Convalescent. 14th. Return of head-ache, and, on the day following, the tongue again became white; but these symptoms disappeared the succeeding day, and, on the 27th, he was dismissed cured. These two cases afford fair specimens of the combination of symptoms, and of the degree of their severity, in the synochus of London, as it occurs in its mildest form. Case III. Emma Gladish. Admitted into the hospital on the 12th day of fever. Attack commenced with usual symptoms. The pain in the head, which had been severe for some time, had entirely subsided on the day of her admission. The mind was now quite indistinct; she could scarcely answer any question that was put to her; the eyes were dull and heavy; she had no sleep; there was great restlessness, and occasionally wandering delirium; there was no tenderness of abdomen; the tongue was red, furred and dry; the stools were passed in bed; the pulse 105, of good power. 13th. Sleep rather more tranquil; less wandering; mind a little more distinct; stools still passed in bed; pulse 100. 14th. Much noise through the night; occasionally started out of disturbed sleep with screaming; tongue red, glazed and dry; stools passed in bed; pulse 96. 15th. Rather more sleep; talkative delirium; tongue somewhat cleaner; pulse 100.
- 74. 16th. Longer and more tranquil sleep; mind more distinct; expression of eyes still dull and heavy; tongue more clean, more moist; stools only partly passed in bed. 17th. More sleep than on the preceding night; mind still more distinct; complains to-day of some tenderness of abdomen on pressure; tongue nearly clean; two stools no longer passed in bed; pulse fallen to 72. 19th. Slept well; mind clearer; eyes more animated; expression of countenance brighter; other symptoms the same. 26th. Continues to improve; skin cool, soft, and moist; pulse 78. 27th. Convalescent; but the convalescence was slow and tedious, as it almost always is after so severe an attack of cerebral disease; she was dismissed cured on the 40th day from the commencement of the attack. The reports of the 15th, 16th, and 17th days illustrate very clearly and strikingly the changes which have already been stated to indicate recovery. Case IV. Elizabeth Price, æt. 26, servant; admitted on 11th day of disease. Attacked with ordinary symptoms of fever: at present complains of very severe head-ache; face flushed; intolerance of light; some deafness; mind confused during night; visions of various kinds, such as “waves of the sea rolling,” appear occasionally before her with great vividness; had been on sea four days before she became ill; skin warm; sense of general soreness; abdomen rather hard, but not tender; tongue furred, rather red; much thirst; no appetite; scarcely any sleep, and, when she does, dreams of a frightful nature interrupt her rest; pulse 114, intermittent, of good power, but easily compressed; bowels constipated. C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. Gelid. cap. Haust. Sennæ Sal. c. m. 12th. More sensible since cupping; mind still confused; occasional wandering; scarcely any sleep; pulse 124, sharp, yet easily compressed. 14th. Quiet night, with considerable sleep; head giddy and slightly painful; respiration hurried, apparently cerebral; pupils active; tongue dry; much thirst; pulse 123. Empl. Lyttæ cap.
- 75. 15th. Much screaming; great restlessness during night; complains much of head-ache; pupils active; urine copious, but passed in bed; all the stools passed in bed; pulse 108, easily compressed; has visions before her almost constantly; head very hot. Four leeches have been applied to the temples this morning without relief. Affus. Frigid. cap. ℞. Hydrar. Submuriat. gr. ij. Pulv. Scillæ, gr. j. Pulv. Antimon. gr. iij. M. sumat 4tâ q. h. 16th. No screaming; head less painful, especially when in half- erect posture; mind quite sensible now, but much wandering occasionally; pulse 120, feeble; five stools passed in bed. 24th. No material change until this day; sleep now greatly improved; mind much more itself; tongue beginning to clean; pulse 93; ptyalism. 28th. Ptyalism continues; feels greatly better; appetite returning. From this period she continued to improve, although with several threatenings of relapse; the convalescence was slow and precarious, but she ultimately left the hospital quite well, though not until the 60th day from the commencement of the fever. Case V. Mary Sullivan, æt. 36. Admitted on 14th day of disease; complaint commenced with shivering; pains in the limbs; severe head-ache. Complains now of violent pain of the head; face pallid; expression depressed; scarcely any sleep; abdomen tender on pressure; only one stool for eleven days; tongue foul and dry; pulse 81, not strong; complains, also, of pain under right mamma, preventing inspiration and decubitus. V.S. ad ℥xij. Lotio Gelida cap. Abrad. Capillitium. 15th. Blood with firm buff; pain of head not at all relieved; pain of back, sides, and abdomen severe; no delirium; no sleep; pulse 78, pretty strong. Hirudines viij. temporibus. Pt. Med. 16th. Pain of head much relieved; slept very much better; pulse 66, full and strong. 17th. Pain of head returned, exceedingly severe over the fore-part; pulse 66, full and strong. C.C. ad ℥xij. nuchæ. Pulv. Aper. Mit. h. s. Ol. Ricini c. m.
- 76. 18th. Pain of head gone; countenance more natural; tongue more clean and moist; pulse 76, more soft. Pt. Med. 20th. Pain of head returned; mind confused; pulse 60, strong and full. C.C. ad ℥viij. nuchæ. Pt. Med. 21st. Pain of head gone; mind confused; pulse 66, pretty strong. 22d. Pain of head returned, but in a slighter degree; mind more confused and dull; scarcely any sleep; tongue more foul; pulse 72, soft. Pt. 24th. No longer conscious of pain; mind quite indistinct; lies prostrate on the back perfectly helpless; incapable of turning on the side; occasional retching; some tenderness of abdomen on pressure; pulse 72, strong and full. 25th. Much restlessness; aspect of countenance greatly depressed; stools passed in bed; pulse 75. 26th. Perfectly senseless; almost constant moaning; extreme restlessness; difficult deglutition; pulse 120. 27th. Not spoken since last report; lies prostrate on back; eyes half open and injected; pulse 102, feeble. 29th. Died. If the reader can doubt of the condition of the brain in this case, he is requested to turn to the pathology, where the morbid appearances on dissection are detailed. Slowness of the pulse, with severe and obstinate pain in the head, attended with confusion of mind, is always a highly dangerous-symptom: it invariably denotes intense cerebral disease. Whenever there is such a struggle, as this case exhibits, between the physician and the disease, the disease is sure to conquer. For if the physician, terrified at the name or the duration of the malady, while he resolve to use the lancet, hesitate to employ it to the extent of subduing the disease by the first bleedings, the patient is lost. The partial relief afforded by partial measures is most delusive. The malady speedily recovers its lost strength: the patient never does. There is no practitioner who is capable of being taught by experience that can reflect on the history and progress of such a case as this, on the temporary relief afforded by such treatment, on its ultimate failure, and on the appearances presented on dissection, without regretting that more blood was not taken on the 15th and 16th days, and without at the same time resolving, that the aid he
- 77. offers in future, under similar circumstances, shall be more decisive. The diminution of the pain of the head on the 22d, accompanied with increasing confusion and dullness, with a tongue growing more and more foul, and with a pulse only at 72, might well excite alarm; and accordingly, on the following day, the case was utterly without hope.
- 78. II. Synochus Gravior with Thoracic Affection. There is probably no case of fever, however slight, in which the mucous membrane of the bronchi remains in a perfectly sound state. A certain affection of this membrane, the nature of which will be stated hereafter, appears to be peculiar, to fever, and there is reason to believe that the acutest thoracic affection which is at the same time truly febrile, differs from the mildest case of fever, in which there may be no visible sign of any thoracic disease whatever, only in the degree in which this organ is affected. Sometimes it happens, however, that this membrane is implicated in a more than ordinary degree; and when it is so, it gives rise to peculiar symptoms, constituting the case thoracic. The severity of these thoracic, is not always in proportion to the severity of the febrile symptoms, in like manner as there may be the most intense febrile symptoms, without any indication of thoracic disease: but whenever the thoracic symptoms are sufficiently intense to become prominent, and especially when they occur early or attend on the commencement of fever, they invariably and very considerably aggravate the general febrile symptoms. In these prominent thoracic affections, then, two things happen; first, the symptoms properly constituting the febrile train are modified, and, secondly, new symptoms are added to this train, namely, those which indicate derangement in the respiratory organs. The new and peculiar symptoms to which a moderately acute and an early thoracic affection gives rise, are the following; namely— Pain in the chest, sometimes severe, sometimes only slight; sense of stricture or dyspnœa; inability to expand the chest by a full inspiration without pain or uneasiness; cough frequently aggravating the pain; sometimes dry, sometimes accompanied with frothy mucous expectoration. Respiration sometimes slow and heavy, at other times, on the contrary, short and quick; never natural: perhaps the physician may detect thoracic disease in the more obscure, and measure its extent in the more obvious cases, by observing the
- 79. manner in which the patient breathes, better than by any other single means. The altered respiration is very frequently accompanied with that peculiar noise in breathing which is termed “mucous rattle.” The pulse, in the commencement of this open and decided chest affection, may not be above 80 or 90; it is hardly ever sharp; it is generally weak; now and then it is full and of good strength; but whatever other character it may possess it is almost always soft. In a few days, as the disease advances, it uniformly rises in frequency and becomes weaker. Towards the end of the disease it is almost always hurried and feeble, although cases occasionally occur in which it is observed at this period to become suddenly slow and intermittent. The tongue is usually foul; commonly moist; but, in severe affections and in their advanced stage, it sometimes becomes dry. The skin is often moderately warm, but it is never intensely hot: it is much more common for it to be cool, and to be of a more dusky colour than natural. Such are the usual conditions of the respiratory and circulating systems and of the tongue, the great index of the state of the mucous membrane of the alimentary canal, when the thoracic affection increases so as to become prominent and acute. The manner in which it influences the cerebral affection is commonly by hastening the period at which the pain of the head lapses into confusion and stupor. Early insensibility, assuming the form of a muddled or exceedingly confused state of mind, is a very constant symptom of more than ordinary thoracic affection. Accordingly, the delirium which succeeds or which accompanies this state is always low muttering talkativeness, or incoherent wandering, rather than violent delirium, which last is seldom, if ever, found in combination with severe thoracic disease. The pathological condition of the lung perfectly accounts for this modification of the condition of the brain, as will be shewn hereafter. Case VI. The following case not only shews the insidious manner in which thoracic disease may come on and the severe form it may ultimately assume; but also, the extent of disease from which it is possible that recovery may take place.
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