Reconstructing Clinical Activities: Patient Records in Medical History

© 1992 The Society for the Social History of Medicine

Reconstructing Clinical Activities:Patient Records in Medical History

By GUENTER B. RISSE* and JOHN HARLEY WARNERf

SUMMARY. The past decade has witnessed growing interest among historians in theuse of patient records as one source of information about the medical experiences andperceptions of the past. Drawing examples from studies that employ what are variouslycalled clinical case histories, clinical charts, and patient notes, this essay draws attentionto some of the historiographic possibilities and problems of using patient records. Suchdocuments provide one basis for tracing shifts over time in clinical practice, perception,and discourse; for reconstructing the demographic character of patient populations aswell as the texture of hospital life; for understanding the roles played by ethnicity,gender, class, race, and geography in shaping patient care; and, used in conjunctionwith other kinds of texts, for comparing clinical ideas with clinical activities, andthereby for exploring the relationship between ideology and behaviour. The opportun-ities patient records offer to historians of medicine are substantial, but the papercautions against the assumption that these sources provide somehow privileged accessto clinical reality.

KEYWORDS: age, case histories, class, clinical charts, clinical practice, ethnicity,gender, geography, hospitals, patient records.

Over two decades ago, Erwin Ackerknecht made 'A Plea for a "Behaviorist"Approach in Writing the History of Medicine', by which he meant a 'moreextensive and more critical analysis of what doctors did in addition to whatthey thought and wrote'. He called for historians of medicine to move beyonda preoccupation with 'the great doctors', but such an operational approach tothe medical past was not meant to supplant attention to biomedical ideas.Instead, it was meant to enrich the analysis of medical activity by informationgleaned from less used sources such as diaries, pamphlets, governmentarchives, contemporary novels, travel reports, and letters. Ackerknecht par-ticularly stressed the importance of a 'behaviorist' approach to understandingthe history of medical therapeutics, and as the most promising source, hesingled out 'above all, case histories, with data on treatment, which exist inprofusion, especially after the 16th century'.1

In 1967 when Ackerknecht wrote, historians (medical and otherwise) werealready self-consciously moving away from focusing on the writings of elites.2

* Department of the History of Health Sciences, University of California at San Francisco, 533Parnassus Avenue, Room U-464, Box 0726, San Francisco, California 94143-0726, USA.

f Section of the History of Medicine and Life Sciences, Yale University School of Medicine, L130SHM, P.O. Box33}}, New Haven, Connecticut 06310, USA.

' Erwin H. .Ackerknecht, 'A Plea for a "Behaviorist" Approach in Writing the History ofMedicine', Journal of the History of Medicine and Allied Sciences, 22 (1967), 211-14.

2 Ackerknecht's call for a 'behaviorist' approach to writing history was not unique in the late1960s. See, for example, Robert F. Berkhofer, Jr., A Behavioral Approach to Historical Analysis(New York and London, 1969).

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184 Guenter B. Risse and John Harley Warner

Yet for at least a decade after the publication of his article, and despite anattempt to explicitly dissociate the term from any connotations of Watsonianpsychology, Ackerknecht's 'behaviorist' approach failed to stimulate muchnew research into the history of medical practice. In part the subject may haveseemed too technical for historians lacking medical knowledge, and many ofthose trained in medicine, including Ackerknecht, instead adopted a presentistapproach that routinely disparaged agents and methods previously believed tooffer cures. The systematic use of the clinical case history as a source forgauging the actual practice of medicine as well as the social nature of healingrelationships therefore remained little cultivated.

To stimulate its use, a seminar on 'unexplored resources for the socialhistory of medicine' took place a decade later, in 1977, at the annual meetingof the American Association for the History of Medicine in Madison,Wisconsin. The session focused on the employment of institutional medicaldocumentation, including patient records, physicians' correspondence, finan-cial and miscellaneous bureaucratic accounts. Two studies mentioned werethe systematic exploration of nineteenth-century patient files at a Bostonhospital for a study on the use of anaesthetic agents, and a canvass of thepatient records of antebellum Massachusetts asylums.3 At the seminar, discus-sion focused on the complex nature of patient records and the overlapping,often conflicting agendas of those medical professionals who created them.Participants were, in general, enthusiastic about the potential value of suchdocumentation as an untapped source of historical information.4

More recently there have been signs that the use of patient records iscoming into vogue. Nevertheless, many historiographic surveys of the historyof medicine published during the past decade omit any specific reference topatient records, while those that mention them at all do so only briefly.Indeed, no systematic attempt has been made to assess the importance, range,and problems peculiar to the use of these documents.5 Yet, the case history -variously called the patient record, clinical chart, or patient notes - is a keydocument, central to understanding the discourse and practice of medicine.

3 Martin S. Pernick, A Calculus of Suffering: Pain, Professionalism, and Anaesthesia in Nineteenth-Century America (New York, 1985); Barbara G. Rosenkrantz and Maris A. Vinovskis, 'Sustaining"the Flickering Flame of Life": Accountability and Culpability for Death in Ante-BellumMassachusetts Asylums', in Susan Reverby and David Rosner (eds.), Health Care in America:Essays in Social History (Philadelphia, 1979), pp. 155-82. See also James F. Gill arid Thornton W.Mitchell, 'Disposition of Medical Records in State Mental Hospitals', American Archivist, 26(1963), 371-8.

'This concern has continued. See A. Nicol andj . Sheppard, 'Why Keep Hospital Records?',British Medical Journal, 290 (1985), 263-4. See also Proceedings, Hospital Clinical Records Symposium,8 May 1985, London, King's Fund Centre, 1985.

5 The utility of patient records as a historical source is noted briefly in Judith Walzer Leavitt,'Medicine in Context: A Review Essay of the History of Medicine', American Historical Review,95 (!99o). 1471-84; Kenneth M. Ludmerer, 'Methodological Issues in the History of Medicine:Achievements and Challenges', Proceedings of the American Philosophical Society, 134 (1990), 367-86;and John Harley Warner, 'Science in Medicine', in Sally Gregory Kohlstedt and Margaret Rossiter(eds.), Historical Writing on American Science: Perspectives and Prospects (Baltimore and London,1986), pp. 37-58-

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Reconstructing Clinical Activities 185

Many historians who have employed patient records follow in the footstepsof the new social history, with its quest for sources that can help reveal pastsocial experiences and mentalities as well as quantitative information. Othershave turned to the patient record as one resource in pursuing a cultural historyof medicine that seeks to integrate a social history of ideas with an intellectualhistory of experience. Together with other medical documents such asphysicians' diaries, professional journals, letters, notes, essays, and books,patient files are important artefacts left behind by past generations; they areunique constructions that allow us to observe the social and technical structureof contemporary healing.6

This essay seeks to draw attention to some of the ways in which patientrecords - both institutional and those kept in private practice - offer thehistorian a rich and often unique source of information. Yet even thoughmuch valuable information can be obtained from clinical charts, attempts tolocate and use them demand a substantial investment of time and effort on thepart of the prospective researcher. For many projects, such increased labourdoes not yield enough information to warrant the effort. Indeed, the recon-struction of medical behaviour and its meaning on the basis of these and othersources is far more problematic than Ackerknecht's original suggestionimplied.

What Is a Patient Record?

Patient records vary a great deal in both length and content, depending onindividual professional prejudices and the social circumstances surroundingtheir composition.7 But while not cast in a single mould, these records possessa number of features that have been relatively consistent across time andinstitutions. A case history usually begins with demographic informationabout the patient: name, sex, and age, followed by marital status andoccupation, and sometimes place of residence, nationality, race, and religiousaffiliation. Indeed, such general characteristics of patient populations are oftenthe most accessible information in patient records, either private case booksor hospital ward books.

For hospital and dispensary records, the date of admission to the institutionis generally indicated, at times with information about the admitting ward orservice. The records may also contain both date of discharge, and status upon

6 For example, archivists as well as historians have identified records and record-keeping inhospitals as important areas for study. Development of hospital records is discussed in detail byBarbara L. Craig, 'Hospital Records and Record-keeping c. 1850-1950'; Part I: The Developmentof Records in Hospitals, Archivaria 19 (1989/90), 57—87. Her survey is based on 57 hospitals — 27in London, England, and 28 in Ontario, Canada. For an analysis of the problems that faceinvestigators, see Robin G. Keirstead, 'An Archival Investigation of Hospital Records', (M.A.thesis, University of British Columbia, 1985).

7 Stanley J. Reiser, 'Creating Form out of Mass: The Development of the Medical Record', inEverett Mendelsohn, (ed.), Transformation and Tradition in the Sciences, Essays in Honor of I. B.Cohen (Cambridge, 1985), pp. 303-16.

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discharge. This information, obtained from admission registers as well asward books, allowed authorities at voluntary hospitals to compose favourabledischarge statistics and thereby justify expenditures to their vigilant subscri-bers. Using this data, historians can begin to draw patient profiles, toreconstruct patterns of medical practice, and to explain admission anddischarge decisions.

Especially in the instance of clinical charts from psychiatric hospitals, theinformation collected by the admitting physician often recounts in great detailthe patient's behaviour prior to institutionalization, including informationprovided by relatives and friends, rather than by the patient. Althoughmodulated by the needs and biases of the recording alienist, these historiesdepict contemporary social life and can reflect how local communities nearthe hospital defined insanity, a point exemplified by Ellen Dwyer in her workon nineteenth-century asylums in New York State. Authorities systematicallycollected such data in the hopes of establishing a true epidemiology of mentalillness.8

Information about past health problems and the circumstances leading upto the present crisis is usually linked to a narrative of the patient's complaints.Descriptions of the salient symptoms and signs elicited by the physicianthrough inspection or physical examination are often followed by a tentative,working diagnosis. How was the diagnosis made? Were particular signsregarded as pathognomonic? To understand its social and medical meanings,a diagnosis must be placed within a contemporary classification system.Depending on the amount of information provided, historians can follow,and perhaps even reconstruct, the clinician's decision-making process.

Subsequent entries track the patient's complaints and manifestations ofsickness, disease complications, ameliorating therapies, and outcome. Some-times such entries were made two or more times a day, sometimes only onceevery few days, and occasionally only at discharge or upon death. Thefrequency of progress notes depended both on the patient's condition and theavailability of transcription personnel. In more recent times, the clinical recordmight also contain the results of laboratory and pathology tests, as well as

8 Ellen Dwyer, Homes for the Mad: Life Inside Two Nineteenth-Century Asylums (New Brunswickand London, 1987). In her ongoing study of the patient case histories from 1896—1950 of NewYork's Craig Colony for Epileptics, Dwyer is further revealing the rich use that can be made ofsuch records. See 'Stories of Epilepsy, 1880-1930', in Charles E. Rosenberg and Janet Golden(eds.), Framing Disease (Rutgers University Press), in press. See also Elizabeth Lundbeck,Psychiatry and Everyday Life, 1900—1930, forthcoming; Mary E. Fissell and John V. Pickstone,'Contexts of Committal: Asylums, Families, and Towns in the Manchester Region, i860—1930',paper presented at the annual meeting of the American Association for the History of Medicine,Baltimore, 12 May, 1990; Cheryl Lynn Krasnick Warsh, 'Moments of Unreason: The HomewoodRetreat and the Practice of Early Canadian Psychiatry, 1883—1923', (Ph.D. diss., QueensUniversity, Ontario, 1987): and idem, 'The First Mrs. Rochester: Wrongful Confinement, SocialRedundancy, and Commitment to the Private Asylum, 1883-1923', Canadian Historical AssociationHistorical Papers (Windsor, 1988), pp. 45-167. Freud's early clinical activities in Dr TheodorMeynert's psychiatric clinic at the Allgemeines Krankenhaus in Vienna have been documented onthe basis of 92 patient records, half of them composed by Freud himself: Albrecht Hirschmuller,Freuds Begegnung mil der Psychiatrie, (Tubingen, 1991).

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findings from radiologic and other technologically-assisted examinations.9

Finally, the chart of a surgical patient might include anaesthesia records,surgical protocols, and postoperative status notes.

While the bulk of the extant documentation regarding patients comes frominstitutional sources - generally hospitals, asylums, and outpatient clinics -records from physicians' private practices often survive as well. MichaelMacDonald's use of medical consultation records from a seventeenth-centurypractice, for example, explored contemporary views of madness. Based onthe patient charts composed by Richard Napier, a seventeenth-century Englishminister, astrologer, and healer, the author compellingly demonstrated how arich set of private records can be employed to 'illuminate the mental world ofordinary people'.10 Another study of Napier's nearly forty thousand patientrecords reconstructed contemporary disease epidemiologies, networks ofpatient referral, and patterns of health care in a typical English village duringthe early 1600s." Also using private practice records, J. Worth Estes hasreconstructed the shared and idiosyncratic prescribing behaviour of threephysicians in colonial New England.12

The signal advantage of patient records obtained from private practice isthe access they provide to information about medical behaviour in the kind ofcontext wherein, for most of history, the vast majority of healers practised.Hospital case books represent a collaborative endeavour, whereas those keptin domiciliary or office practice document the work of a single practitioner,sometimes making it much easier to discern consistent patterns in theirdiagnostic schemes, therapeutic strategies, and health advice. Jacalyn Duffinhas been able to use the exceptionally complete records kept by one Ontariogeneral practitioner between 1847 and 1875, for example, to trace his changingwork-load and income, the composition of his clientele, the diseases heconfronted, and the therapies he prescribed.13

Sometimes it even becomes possible to relate the healers' actions to theirideas, writings, and to the patient's social class. One study of some threethousand consultation letters written in Scotland by William Cullen to patients

9 L. S. Jacyna has provided one model of how patient charts and pathologists' journals can beused together to assess the role of pathological examinations in diagnosis and patient care; see his'The Laboratory and the Clinic: The Impact of Pathology on Surgical Diagnosis in the GlasgowWestern Infirmary, 1875-1910', Bulletin of the History of Medicine, 62 (1988), 384-406.

10 Michael MacDonald, Mystical Bedlam: Madness, Anxiety and Healing in Seventeenth-CenturyEngland (Cambridge and New York, 1981), p. xii.

11 Ronald C. Sawyer, 'Patients, Healers and Disease in the Southeast Midlands, 1597-1634',(Ph.D. diss., University of Wisconsin, 1986). Other reconstructions of the practice of individualhealers include Robert Jiitte, 'A Seventeenth-Century German Barber Surgeon and His Patients',Medical History, 33 (1989), 184—98; and Edna Hindie Lemay, 'Thomas Herier, a Country Surgeonoutside Angouleme at the End of the XVlIIth Century. A Contribution to Social History', Journalof Social History, 10(1976-77), 524-37.

12 J. Worth Estes, 'Therapeutic Practice in Colonial New England', in Philip Cash, Eric H.Christianson, and J. Worth Estes (eds.), Medicine in Colonial Massachusetts, 1620—1820 (Boston,1980), pp. 289-383.

13 Jacalyn M. Duffin, 'A Rural Practice in Nineteenth-Century Ontario: The ContinuingMedical Education ofjames M. Langstaff', Canadian Bulletin of Medical History, 5 (1988), 3-28.

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and their physicians between 1755 and his death in 1790 allowed such ananalysis. Cullen's approach to the treatment of upper- and middle-classpatients provides a valuable insight into eighteenth-century healing relation-ships and client control.u Another study based on the working-class practiceof the German physician Alfred Grotjahn between 1896 and 1906 sheds lighton the everyday actions of a young 'scientific' physician, his hospital referrals,treatments, and fees.15

One limitation of case records derived from private practice is that theyseldom support a very systematic analysis. Records kept by an individualpractitioner contain far fewer cases and span a much narrower band of timethan do institutional records. Given the particular circumstances surroundingeach medical practice, case books from private practice may be more difficultto compare than ward journals. When such documents were kept in privatepractice, they often contained only 'interesting' or 'complicated' cases, thusproviding an unrepresentative sample of patients, their diseases, and treat-ments. Accordingly, generalization and depiction of broad trends based onprivate practice records must be severely qualified.

In contrast to the case book, one type of private-practice record is abundantand admits of systematic historical analysis - the financial record. Privatemedical practitioners ran small businesses, and even those who did not havethe time or take the trouble to record patient histories usually kept some kindof day books, which survive in abundance. Such records have evident valuein understanding the workaday business of medicine, as Irvine Loudon hasshown in a reconstruction of the economy of an English general practiceduring the 1830s based on a practitioner's case book.16 In the past as at present,the sorts of medical behaviour most closely documented were billableprocedures. Therefore, financial records of private practice, at least during thenineteenth century, will tell the historian virtually nothing about diagnosticprocedures and little about prescribed drugs (often-entered in ledgers merelyas 'prescription' or 'medicine'). In contrast, a surgical procedure such asvenesection was invariably recorded, along with the fee. It is for this reasonthat more can be known about how the use of venesection by individualphysicians in domiciliary practice changed over time and varied geographicallythan the use of other important therapies.17

One helpful indicator of physicians' prescribing behaviour is the pharmacy

14 Guenter B. Risse, 'Managing the Rich and Famous: William Cullen's Mail-order Physic inthe Eighteenth Century', in William Cullen and the World of Eighteenth-Century Medicine(forthcoming).

15 Paul Weindling, 'Medical Practice in Imperial Berlin: The Casebook of Alfred Grotjahn',Bulletin of the History of Medicine, 61 (1987), 391—410.

16 I. S. L. Loudon, 'A Doctor's Cash Book: The Economy of General Practice in the 1830s',Medical History, 27 (1983), 249-68; and see also Carole Rawcliffe, 'The Profits of Practice: TheWealth and Status of Medical Men in Later Medieval England', Social History of Medicine, 1(1988), 61-78.

"John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity inAmerica, 1820—1885 (Cambridge, Massachusetts, and London, 1986), pp. 83—4, 95—7.

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prescription book. This ledger offers one means of gauging how frequentlythe doctors of a community prescribed particular drugs. One pilot studyanalysed 549 prescriptions on file for the year 1854 in a Burlington, NewJersey pharmacy.18 The prescriptions, written by three local practitioners,reflected the contemporary knowledge and practice of physicians trained inPhiladelphia. Because established pharmacies often stayed in business for morethan a generation, these sources are especially well suited for studyingchanging patterns of drug use over time. And since the relative frequency ofuse and dosage are readily quantifiable, pharmacy prescription books arepromising as tools in comparing regional variations in prescribing behaviour.As with the physician's financial records, pharmacy prescription booksfundamentally are business records; they survive in impressive quantities,especially from the mid-nineteenth century onward.

So far, scholars who have sought to use patient records seem to haveencountered relatively little difficulty in gaining access to them when available,provided that the materials are old enough, and of a character not to raiseserious issues of confidentiality. Psychiatric and more recent medical recordsoften remain restricted. However new legal questions of authorship, owner-ship, and access to clinical charts threaten to complicate matters for futureresearchers. The burden of maintaining access to such documents restssquarely on the historians themselves, and much will depend on the mannerin which scholars use. such information and manage the issue ofconfidentiality.19

Given their bulk and institutional location (most clinical charts remain inmedical records departments), patient records are rapidly vanishing, victimsof space constraints and the indifference of administrators unfamiliar with thehistorical value of such documents. Historians must therefore become activein working with archivists to support the collection and safeguarding ofpatient records, their transfer to archives, and maintenance in proper storagefacilities. Systematic microfilming or videotaping of the documentationshould be explored seriously whenever collections are threatened withdestruction.

Patients and Physicians: Their Voices and Relationships

Patient records are surviving artefacts of the interaction between physiciansand their patients in which individual personality, cultural assumptions, socialstatus, bureaucratic expediency, and the reality of power relationships areexpressed. Converting complex clinical perceptions of illness into written

18 David L. Cowen, Louis D. King, and Nicholas G. Lordi, 'Nineteenth-Century DrugTherapy: Computer Analysis of the 1854 Prescription File of a Burlington Pharmacy', Journal ofthe Medical Society of New Jersey, 78 (1981), 758—61; and see Warner, The Therapeutic Perspective,pp. 308, 310.

19 See the recently approved code of ethics of the American Association for the History ofMedicine.

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190 Guenter B. Risse and John Hariey Warner

narratives involves both selection and interpretation; and although intendedby clinicians to lay bare the course of illness and therapy, much else is oftenrevealed. Depending on institutional norms and personal preferences, textualmeanings are deeply imbedded in the records and require tedious excavationand subtle interpretation. In other instances information useful to the historianlies exposed very near the surface.

Especially promising, yet little explored, is the information preserved inhospital case books about patients' perceptions of illness and medical treat-ment. In American hospitals through the 1860s, the patient's own account ofthe illness experience was routinely written down shortly after admission tothe institution, a process in which ward clerks typically acted as scribes forthe sometimes illiterate charity patient. No doubt the history-taker frequentlyreinterpreted, misunderstood, or dismissed what the patient said, yet accountsquoted in the words of labourers or domestic servants abound. These storiesprovide a unique record of popular health beliefs among lower-class patients,notions of disease causation, and chronicles of self-help practices. In oneFrench example from the Salpetriere hospital, medical dossiers and casehistories from the 1850s and 1870s record the voices of patients believed tosuffer from hysteria. These fragmentary narratives are quite revealing, as theydemonstrate the social marginality and patterns of abuse of contemporaryFrench working-class women.20

Records that express the opinions of the medical staff regarding theirpatients also offer fascinating insights for the historian seeking to capture thecharacter of the doctor-patient relationship in the wards of charity hospitals.At some institutions the staff freely and openly recorded in the case bookstheir opinions of individual inmates, expressing a ridicule and a compassionrarely found so bluntly in published literature. At the Commercial Hospitalof Cincinnati (especially prior to the 1860s) the interns expressed theiramusement, scorn, or disgust for patients in the hospital's official records.They joked about the ethnicity of the sick, remarked on drinking and sexualhabits (especially of female patients), and derided their laziness and ignorance.Yet these same interns occasionally wrote of their empathy and concern withthe plight of Irish immigrants brought directly from the boats to the hospital'sbeds exhausted, but not necessarily diseased.21

Patient records can also help reveal the texture of hospital life, including theadmission process, the visits by physicians and nurses, the routines of

MJann A. Matlock, 'Scenes of Seduction: Prostitution, Hysteria, and Reading Difference inNineteenth-Century France', (Ph.D. diss., University of California, Berkeley, 1988). Seeespecially her selected patient reports in Admission Registers, Salpetriere Hospital, 1845—1865. Seealso Mark S. Micale, 'Charcot and the Idea of Hysteria in the Male: A Study of Gender, MentalScience, and Medical Diagnostics in Late Nineteenth-Century France', Medical History, 34 (1990),363-411, and Mary Fissell, 'The Disappearance of the Patient's Narrative', in Andrew Wear andRoger French (eds.), British Medicine in an Age of Reform, 1760-1840 (London, in'press).

21 The case records of the Commercial Hospital of Cincinnati (later the Cincinnati GeneralHospital), 71 vols., 1837-81, are deposited in the History of the Health Sciences Library andMuseum, University of Cincinnati; see Warner, The Therapeutic Perspective, pp. 108-14.

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receiving meals and medications, the recovery or dying of patients, and thepresence of visitors and students. The transcribers focused on patients' medicalproblems, but they also wrote reflectively on the difficulties of maintaining anordered, healing environment. Keeping order in the wards, an ideal enshrinedin countless hospital regulations, was usually difficult; thefts occurred, fightsbroke out, patients were punished for violating the rules, some inmatesescaped, others had hysterical and epileptic fits or raved all night in theirfebrile delirium. Though confusion and turmoil were the norm, there werealso more pleasant aspects to hospital life. At the Edinburgh Infirmary, forexample, convalescing patients could roast their own meat in the fireplaces,spin cotton, and visit relatives or nearby taverns.22

Categories of Historical Analysis

The patient record as a document is a revealing indicator of the changingclinical mentality. For some, case records remain a remarkably unexploredgenre of literature. Contained in hospital archives, professional journals andbooks, practitioners' ledgers, diaries, and letters offer promising material forexegesis. Reading and interpreting the patient record as a distinct literary textprompts questions of structure and terminology, style and tone, authorshipand audience. From such analyses it is possible to retrieve the cultural,institutional, and professional perceptions, values, and power that the casehistory reflects and encodes. How were assumptions about the likely courseof an illness scripted in the narrative, for example? To what extent was theselection and employment of particular clinical observations shaped by tacitmodels of the natural history of the suspected disease?

While the basic narrative structure of the case history has been remarkablydurable over the past two or three centuries, both the content of that narrativeand the language used in composing it have changed dramatically. One projectattempts to study the shifts that occurred in medical narratives as theintroduction of methods of physical diagnosis and 'objective' signs of diseaseearly in the nineteenth century superseded the patient's own accounts, anddiminished the need and ability of the sick to 'read' their own bodies. In thisway, the constant medical redefinitions of sickness and patienthood arerevealed. Later in the nineteenth century, as other studies have noted, the

22 Some of this information is contained in Royal Infirmary of Edinburgh, Report of a Committeeon the State of the Hospital, Edinburgh, 1818, as well as in several student notebooks. For moredetails consult Guenter B. Risse, Hospital Life in Enlightenment Scotland, Care and Teaching at theRoyal Infirmary of Edinburgh (Cambridge, 1986), especially sections devoted to activities in thehospital wards. Depictions of hospital life informed partly by case records include Anne Digby,Madness, Morality and Medicine: A Study of the York Retreat, 1796—lgtq (Cambridge, 1985); CharlesE. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (New York, 1987); andNancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping,1840—188} (Cambridge, 1984). See also Anne Digby, 'Quantitative and Qualitative Perspectiveson the Asylum', and Guenter B. Risse, 'Hospital History: New Sources and Methods', in RoyPorter and Andrew Wear (eds), Problems and Methods in the History of Medicine (London, 1987),pp. 153-74 and 175-203.

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most evident change was from words toward numbers and visual representa-tions of bodily disorder. To the extent that language reflects and shapesthinking, such transformations - far more pronounced in terse patient recordsthan in the more discursive medical literature - mark an important transitionof professional views concerning disease and patienthood. Over time theindividuating factors of patient background and environment were excludedfrom the records in favour of the quantified physiological parameters thatcould be graphically displayed and easily gauged against standardized norms.23

Much of the same shift in clinical perception reflected by increasingquantification is also evident in changing word usage. Early in the nineteenthcentury, for example, the various facets of the patient's condition were usuallydescribed in terms of their 'naturalness', reflecting the clinician's attention toidiosyncrasy, to what was and was not natural for the sick individual. By thelate nineteenth century, however, 'natural' was virtually entirely supplantedby 'normal' in medical records, mirroring the clinician's preoccupation withcomparing measurable signs with standardized norms.24 Thus what has beencalled 'the disappearance of the sick-man from medical cosmology'25 can beclosely charted as it was expressed in changing perceptions on the wards.

Patient records also provide access to descriptive demographic and behav-ioural information not available elsewhere. The questions asked might besimple ones..Did clinicians at a particular institution in 1837 routinely use thestethoscope in examining patients with pulmonary complaints? Was antitoxinadministered to all patients diagnosed as having diphtheria in 1897? A moreambitious use of the records might inform a cross-sectional reconstruction ofclinical behaviour in 1837 or 1897.

Such use of patient records as a basis for description is a task admirablysuited for cliometric analysis, aided by the computer. A quantitative descrip-tion of information gleaned from patient records is helpful, and perhaps apractical necessity, especially for the researcher who wishes to describe changeover a long period of time or compare professional behaviour in differentclinical contexts. Patient records are already broken up into discrete units orindividual cases, each containing specific bits of information, such as age, sex,occupation, diagnosis, and medical interventions, that can be easily collectedand quantified. For individuals interested in the nature of change in medicalpractice, the introduction of particular laboratory tests or drugs may likewise

23 Personal communication to G. B. R. The author, Stephanie Kiceluk, is examining thepsychiatric case history, focusing primarily on the evolution of certain conceptual and stylisticshifts in the nineteenth and twentieth centuries. See also Reiser, 'Creating Form Out of Mass';John Harley Warner, 'From Specificity to Universalism in Medical Therapeutics: Transformationin the Nineteenth-Century United States', in Yosio Kawakita, Shizu Sakai, and Yasuo Otsuka(eds.), The History of Therapy (Tokyo, 1990), pp. 193-223; and Warner, The TherapeuticPerspective, pp. 153-9, 243-57.

24 On the use of the terms 'natural' and 'normal' in patient charts, see Warner, The TherapeuticPerspective, p p . 85—91.

25 N. Jewson, 'The Disappearance of the Sick Man from Medical Cosmology 1770-1870',Sociology, 10 (1976), 225-44.

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be traced quantitatively. All these facts can be coded and statistically evaluated,providing valuable baseline demographic and behavioural contours.

Even if only patient registers - not true case books - for hospitals anddispensaries survive, historians can obtain from them statistical informationabout patients, diseases, and therapeutic procedures. What kind of patientswere admitted to a British infirmary in the eighteenth century? What weretheir age distributions? How many of them were diagnosed as having a fever?How long did the patients stay in the institution? What was the rate ofinstitutional mortality? Even though purely descriptive, this initial task ofestablishing patient profiles, a spectrum of diseases, and a core materia medicashould not be dismissed as trivial, since it can reveal previously unrecognizedpatterns of clinical activity. Here, however, the quality and abundance of dataoften pose new problems.

As they set out to organize the information contained in such patientrecords, scholars must exercise caution, or risk being buried under mounds ofcomputer printouts. In the case of patient records from the eighteenth-centuryEdinburgh Infirmary, for example, an effort had to be made to restrict thebountiful diagnostic data, including in the study only some frequent diseasecategories without distorting contemporary definitions and patterns of suffer-ing. What was the meaning of certain terms? One of the great temptations forscholars is to superimpose a modern disease classification system on pastnosology and retrospectively build from patient records a false historicalepidemiology that ignores the changing definition and construction of specificdisease entities. In this example, to provide some framework for meaningfulanalysis, all original diagnostic labels taken from an old register of patientsand individual case histories were arranged, as a compromise, under broadcategories based on organ systems primarily affected by the disease, such asthe genito-urinary and respiratory systems. The reinterpretation can be risky,since it imposes a new level of classification on the original nosology.26

Statistical information merely provides the starting point for another typeof analysis, including inferences that allow investigators to pursue newquestions, analyse professional behaviour, consider financial and politicalcontexts. Why was this particular fact recorded in the first place? Who did it?How and when? How does the chart and registration system actually reflecthospital life? Is the high cure rate a function of effective medical care, careful

26 Risse, Hospital Life, especially chap. 3, pp. 119-76. T. H. Turner, however, is using the1845-1890 case books from the Ticehurst Asylum in Sussex partly as a basis for makingretrospective diagnoses of Victorian patients. An early report on his study is T. H. Turner, 'ThePast of Psychiatry: Why Build Asylums', Lancet, 2 (1985), 709-11; for an earlier effort, seeFranklin S. Klaf and John G. Hamilton, 'Schizophrenia - A Hundred Years Ago and Today',Journal of Mental Science, 107 (1961), 819-27. A quite different use of the Ticehurst case-notes ismade in Charlotte Mackenzie, 'Family Asylum: A History of the Private Madhouse at Ticehurstin Sussex, 1792—1917', (Ph.D. diss., University of London, 1987); and see idem, 'Social Factorsin the Admission, Discharge, and Continuing Stay of Patients at Ticehurst Asylum, 1845-1917',in W. F. Bynum, Roy Porter, and Michael Shepherd (eds.), The Anatomy of Madness: Essays in theHistory of Psychiatry (London and New York, 1985), vol. 2, pp. 147—74.

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selection of patients with mild, self-limited illnesses, or deliberate misrepre-sentation? Similar studies can be done with private-practice case books,mapping not only the demographics of an individual practice, but investigat-ing the reasons for patient selection, number of visits, and differences intherapeutic approach.

Beyond reconstructions of private and institutional settings, patient recordshelp elucidate the relationship between hospitals and society at large andprovide a window into the broader conditions of social life. The records helpdefine the patient population base, and help place the hospital's spectrum ofdisease in the context of contemporary epidemiology for that region.27

Records display the social, administrative, or economic filters operating toshape the indices of suffering encountered in the files. Patient records inviteone to compare the causes of hospital death with those recorded in local citybills of mortality. From the available information, inferences can be madeabout social health conditions. Consider a study by P. C. and W. P. Ward,who systematically extracted infant birth weights from obstetrical chartsbelonging to a series of municipal hospitals in Canada and Europe during thenineteenth-century industrial revolution. The researchers linked this data,reflecting maternal nutritional deficiencies, to the social class of the mothersand hence to contemporary urban conditions.28 So, too, another historian hasused the mid-twentieth-century inpatient records of a rural hospital in SouthAfrica to reveal seasonal variations in the admission of infants for malnutri-tion. Using this information as a starting point, she goes on to show howdisruptions in infant feeding stemmed from more fundamental disruptions intraditional work patterns and living arrangements that particulary changedthe nature of women's labour.29

Another important category of analysis deals with the question of clinicaldecision making and innovation. How and when was a new therapy ordiagnostic procedure first introduced into hospital practice, and when did itactually become assimilated into routine practice? Using selected patient files,one recent study attempted to determine the. actual introduction of thestethoscope by Rene Laennec into hospital practice. In the process, a signific-ant lag in the use of the instrument was uncovered, thus revising themythology surrounding its discovery.30

27 See for example Hilary Marland's Medicine and Society in Wakefield and Huddersfield, 1780—1870,(Cambridge, 1987).

28 W. P. and P. C. Ward, 'Infant Birth Weight and Nutrition in Industrialized Montreal',American Historical Review, 89 (1984), 324—45. And see Janet Golden's use of patient records fromthe New England Hospital for Women and the Boston Lying-in Hospital to identify thecharacteristics of women discharged into the community as wet nurses, in From Breast to Bottle: AHistory of Wet-Nursing in America (in p r e p a r a t i o n ) .

29 Diana Wylie, 'The "Ignorance of Mothers" and the Health of Children in Twentieth CenturyPondoland', paper for discussion at University of London Institute of Commonwealth Studies,postgraduate seminar on 'The Societies of South Africa in the 19th and 20th Centuries', London,4 May 1989.

30 Mirko D. Grmek, 'L'invention de l'auscultation mediate, retouches a un cliche historique',Rev du Palais de la Decouverte, 22 (1981), 107—16. The actual use of the stethoscope as revealed by

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Joel Howell, who studied the introduction of diagnostic technology intothe Pennsylvania Hospital from 1897 to 1927, took a similar approach.Focusing on the early use of x-ray machines and electrocardiographs, hedemonstrated that what clinicians actually did with these instruments some-times diverged from what was published in the hospital's annual reports,which led him to distrust the logic of technological innovation detailed in thepublished works. From his analysis of patient records, Howell concludes thatthe ways in which these instruments were employed direct the historian'sattention to the internal dynamics and organization of the institution wherethe technology was applied. Systematically using patient records to find suchtechnological markers, the author proposes to conduct a broader study ofdiagnostic technologies in selected American hospitals during the early decadesof the twentieth century, highlighting the institutional factors responsible fortheir appearance and use.31

Not only can we determine dates, we can also reconstruct factors thatinfluenced the adoption of a particular mode of institutional clinical action.Large-scale statistical analyses of numerous patient records can provide modelsbased on such factors as patient demographics, profiles of professional staff,diagnostic categories, and length of stay. Such models provide important'macro'-level views of the contexts in which therapies were introduced,routinized, and abandoned. Yet it would be mistaken to assume that becausea derived model has a high statistical correlation, our work as historians hasended. In fact, it has just begun. Another, 'micro' analysis needs to beintroduced to provide the level of detail necessary to determine what thevarious data categories actually mean at the individual level.

To illustrate by example, one study being undertaken by Jack Pressmananalyses the use of psychosurgery at an elite American mental asylum in the1940s.32 The study assumes that it is not enough simply to describe statisticallythe 'average' psychosurgery patient in terms of age, sex, and length of stay,for no insight can be found into the reasons why a particular patient wasselected for this specific treatment. Indeed, using the routine information, thesample of psychosurgery-patients looks no different from the rest of thehospital population. However, a closer inspection reveals differences in thepatterns of use within each psychiatric diagnosis as compared to the non-

the clinical records of Laennec's English translator, Sir John Forbes, is explored in Jennifer AnneHeller, 'Medical Heretic or Orthodox Physician? An Examination of the Life of Sir John Forbes',(B.A. senior essay in history of medicine, Yale College, 1989).

31 Some of this ongoing work is presented in Joel D. Howell, 'Early Use of X-Ray Machinesand Electrocardiographs at the Pennsylvania Hospital', Journal of the American Medical Association,255 (!98<>), 2320-3; idem, letters to the editor, Journal of the American Medical Association, 256(1986), 1444-6; and idem, 'Patient Care at Guy's and the Pennsylvania Hospital, 1900-1920', inRonald L. Numbers and John. V. Pickstone (compilers), British Society for the History of Scienceand the History of Science Society. Programs, Papers, and Abstracts for the Joint Conference, Manchester,England, 11-13 July '98g (Madison, 1988), pp. 247-54.

32 Jack Pressman, Active Treatment: Psychosurgery and the Rise of Scientific Psychiatry in America(in preparation for Cambridge University Press).

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psychosurgery patients. In the schizophrenic population, for instance, surgerywas performed on younger patients, while in the manic-depressive group,psychosurgery was performed preferentially on older patients.

This disparity reveals how clinicians regarded the differential prognosticoutlook attached to specific psychiatric diagnoses, and how they went on totreat their patients accordingly. Even so, we have no clue as to why any givenpatient was selected to receive psychosurgery. Thus, the study must proceedto another level by using a statistical model to select those patients who, onthe basis of the macro-level model, should have received a lobotomy, but didnot. Here the contents of the individual patient record become especiallyvaluable. Now, psychosurgery patients and their matched controls are com-pared at the level of daily entries of nurses' notes for clues as to what ledpractitioners to make the fateful clinical decision to operate. Both the levels ofanalysis work best when used in tandem. The latter, richest in historicalincident, are likely to be the most informative, since they most faithfullyreflect the clinicians' therapeutic decisions.

But how are we to study in such detail literally hundreds or even thousandsof patient records? A careful reading of every file is a herculean task. Thus,scholars should first determine the demographics of the patient populationunder study - the macro-level approach - and concentrate on representativecharts. Current fashions of archival preservation, in which hospital files aresampled or only randomly preserved, render this more subtle approach nearlyimpossible, and future preservation efforts must take this issue into account.There is really no substitute for keeping the entire historical record intact.

Patterns of rejection or discontinuance of certain clinical routines cansimilarly benefit from an analysis of patient records. For example, when andwhy was the inspection of the patient's tongue, traditionally an importantbarometer of illness, abandoned? What happened to the subtle distinctions ofthe pulse that came to be supplanted by numerical expressions? When andwhy did a particular drug cease to be prescribed? Here again, the publishedmedical literature offers only meagre perspectives. More important, we rarelyknow when those officially obsolete routines were actually discontinued inclinical settings, and who made the decision to do so. Why and where do thetreatments persist? In the case of calomel, for example, this once-importantdrug remained in popular use long after it had been discredited in theprofessional literature, and was even dispensed on American naval vessels as acathartic during World War II.33 This suggests that published medical litera-ture offers only one perspective on the process of clinical rejection, and notone that necessarily reveals much about what was actually going on at thebedside. To understand the process through which a therapy or diagnosticprocedure was abandoned, the historian must once again consider textualaccounts in conjunction with information gathered from patient records.

33 Personal communication to G. B. R. from Dr Alvan G. Foraker, Jacksonville Beach, Florida,responding to the author's article on calomel in Mayo Clinical Proceedings, 48 (1973), 57-64.

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So far perhaps the least explored type of analysis is the use of patient recordsto elucidate the process of clinical creativity. How, for example, out of theprotean signs and symptoms displayed by patients, did clinicians actuallyselect those deemed 'significant' in making diagnostic distinctions, such asseparating typhus and typhoid fever? The published record tells us much, butclinical case histories can be used to give new clues about the production ofclinical knowledge. One close study of Laennec's case records, tracing howhis medical ideas grew out of his clinical experience exemplifies thisapproach.34

Ethnicity, Class, Gender, and Geography

Because patient records document the behaviour of physicians dealing withlarge and varied patient populations, they offer singularly rich access toknowledge about how such variables as ethnicity, class, gender, and geog-raphy shaped clinical behaviour. Were certain ethnic immigrant minorities,for example, treated differently when they came to nineteenth- and twentieth-century American dispensaries and hospitals? It is not surprising that theywere, but the clinical records help us begin to define what this actually meantfor their experience of hospitalization and patienthood. Martin Pernick's studyof the early use of anaesthesia in surgery revealed that at the MassachusettsGeneral Hospital, doctors discriminated in practice according to the ethnicity,gender, and age of the individual patient. As the author perceptively observes,differences in treatment reflected the views of contemporary physicians whotook pride in personalizing their therapies according to the perceived needs oftheir patients. Indeed, mid-nineteenth-century surgeons developed an elabor-ate set of criteria for determining whether any individual patient would suffergreater risk from receiving an anaesthetic, or from the pain of undergoing anoperation unanaesthetized. In their writings, surgeons articulated a socialhierarchy of sensitivity to pain which decreed that a middle-class, native-born, white woman should receive anaesthesia for the same operation that anIrish-born, male labourer would be better off enduring fully sentient. Suchideas on selective anaesthetization were indeed carried out in actual practice.35

Patient records can thus help define the effective meaning of parameters suchas ethnicity in professional decision making. Patient charts can also begin to

•"Jacalyn M. Duffin, 'Laennec: entre la pathologie et la clinique', (Ph.D. diss., Histoire etPhilosophic des Sciences, Paris-I-Sorbonne, 1985); idem, 'The Medical Philosophy of R. T. H.Laennec (1781-1826)', History and Philosophy of the Life Sciences, 8 (1986), 195-219; idem, 'PrivatePractice and Public Research: Laennec's Manuscript Case Records', paper presented at conferenceon 'Researchers and Practitioners: Aspects of French Medical Culture in the Eighteenth andNineteenth Centuries', Blacksburg, Virginia, 20 April 1990.

35 Pernick, A., Calculus of Suffering, pp. 125—95. There is also potential for comparing howpatients were perceived and managed in different services of a single hospital; consider, forexample, H. Hughes Evans' comparison of the records of children admitted to the paediatric andto the general medical services of the Massachusetts General Hospital, in 'The Development ofHospital Care for Children in Boston, 1869-1920', (Ph.D. diss., Harvard University,forthcoming).

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198 GuenterB. Risse and John Harley Warner

reveal how the patient's gender shaped the clinician's behaviour. In Pernick'swork, even experimental surgery was more common on women than men.At Edinburgh, Cullen's hospitalized female patients endured a significantlyhigher percentage of all treatments, from analgesics to diuretics, emetics topurgatives, venesection to blisters.36

The roles played by ethnicity, race, and gender in determining patient careare more readily discerned in hospital patient charts than the role played byclass, at least before the end of the nineteenth century. Exploration of howthe patient's class influenced the physician's behaviour requires comparableclinical records from patients belonging to different social levels, yet beforethe hospitalization of the middle classes, patients were recruited from a singlestratum of society. Comparison is possible, however, if practitioners keptinformation about both their paying and charity patients. One recent studylooks at two dissimilar eighteenth-century sources that reflect the professionalactivities of a single physician: letters of medical advice and hospital charts. Inthis example, the correspondence with wealthy patients displays a carefulprognostic and therapeutic approach primarily based on lifestyle adjustmentand tailored to the individual patient. Patrons were important, not simplytheir diseases. The charity cases, by contrast, prompted early diagnosticlabelling, followed by a much more aggressive management routine, ademonstration that in some respects, lower class-patients were less importantclinically than were their diseases.37

Regionalism as a factor in clinical behaviour can also be clarified usingpatient records. Documents are available from a number of regions withinany particular country, providing opportunities for comparison. In fact, thecorrelation of patient management in different hospitals is important inassessing whether the patterns of clinical behaviour are truly representative ofconcepts and practices widely held by contemporary practitioners, or whetherthey represent regional idiosyncrasies instead. Conversely, regional rivalry

36 The comparisons were made in the treatment of simple fevers. Male and female patients atthe Royal Infirmary in the 1760s and 1770s were subjected to the following treatments (bypercentage). This study is based on a total of sixty-one cases.

PainkillersEmeticsPurgativesBlistersVenesection

Females3091433862

Males7

6421

21

21

For details see Guenter B. Risse, 'Cullen on "Fevers"; Models and Clinical Management',(forthcoming). See also Ornella Moscucci, The Science of Woman: Gynecology and Gender inEngland, 1800-1929, (Cambridge, 1990), p. 128. The author uses case records from two Londonhospitals to demonstrate the marked difference in surgical practice of male gynaecologists in the1860s, suggesting that treatment was not shaped by cultural prejudice against women. Thisevidence relates and also supports the Morantz and Zschoche argument.

37 Guenter B. Risse, 'Cullen As Clinician: Organization and Strategies of an Eighteenth-Century Medical Practice', presented at the symposium William Cullen and the Eighteenth-CenturyMedical World, Edinburgh, 24 August 1990, sponsored by the Royal College of Physicians,Edinburgh. Publication of the papers by Edinburgh University Press is forthcoming.

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between medical centres could have serious consequences for medical practiceand affect the receptivity of doctors to clinical innovations. One studydemonstrates that at Boston's Massachusetts General Hospital, where etheranaesthesia was first demonstrated in surgery, its use became quickly routin-ized. Yet at the Pennsylvania Hospital in Philadelphia, the long-standing rivalto Boston as the American centre for medical learning, the practice was onlygradually adopted.38

Another study that compared therapy and dosage at the MassachusettsGeneral Hospital with contemporary practice at a Cincinnati institutionrevealed that through the 1850s a more aggressive style of medical practiceprevailed in the American West. Such documented differences in clinicalbehaviour suggest that American rhetoric about medical distinctiveness mayhave represented more than just aspirations for separate regional identities;there were sectional variations in training and clinical mentality that made areal difference at the bedside.39 Locally, similar comparisons of patientmanagement in municipal, and private institutions should be made, especiallybetween city hospitals and religious and sectarian institutions. Can one finddifferences in organization and medical practice between a Catholic and aMethodist establishment? How was care given in Chinese hospitals? Finally,at the national level, this kind of historical analysis may be even more fruitful,providing information that could expand and test perceptions of nationalstyles in medical practice that are common in the professional literature.

Ideology and Practice

As a tool for opening up new avenues of historical investigation, patientrecords may well prove to have their greatest utility in permitting a systematicexploration of the relationship between medical ideas and medical activities,between ideology and behaviour. Through patient records the historian candiscern both the use of concepts and the experiences that originally shapedideas and expectations. The descriptions of clinical activity in patient chartsare a key ingredient in developing programmes for a historical sociology ofmedical knowledge. It enables scholars to discern the behaviour that underlayideological positions, just as it lets them assess the meaning of those positionswhen translated into action.

As in the history of science, a focus on practice has recently come to the forein the history of medicine. Partly to understand the process through whichscientific ideas take shape, historians of science have looked closely at theactivities of scientists in the laboratory or in the field. To reconstruct scientificpractice, scholars have turned to laboratory or field notebooks, just as

38 Pernick, A Calculus of Suffering, pp. 201-7.•"Warner, TheTherapeutic Perspective, pp. 83-161.

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historians of medicine are turning to clinical patient records.40 'If we are tounderstand scientific activity at its core', Frederic Holmes has urged, 'we mustimmerse ourselves as fully as possible into those investigative operations,whether they be in the laboratory, museum, field, or lecture hall wherescientists spend the working days of their lives.'41 On the one hand, such closeattention to laboratory operations gives a finer grained narrative of theinvestigative enterprise than the study of published records alone can produce.At the same time, a comparative analysis of scientists' published work withthe private record of activities can restructure our understanding of theirwork. One study, based on Louis Pasteur's laboratory notebooks, brings outthe important differences between private and public Pasteurian science.42 Theextent to which laboratory notebooks inform the author's revisionism may besomewhat unusual, but it exemplifies the new approach: use of historicalknowledge about what scientists actually did to reinterpret the more accessiblerecords of what they said.

For clinicians as for other natural scientists, knowing what they did doesnot necessarily reveal what their behaviour meant. To draw meaning fromdescriptions of behaviour based on patient records, these accounts must beinterpreted in the light of information gleaned from other discursive sources.Physicians often left behind abundant records' explaining their own clinicalbehaviour. However suspect these texts may be as records of actual practice,it is principally through them that the historian begins to understand whydoctors did what they did, what expectations they held about their ownclinical interventions, and how they explained their actions and perceivedtheir consequences. To reveal what our reconstructions of clinical conductmean, we must compare behaviour with its portrayal in texts.

Comparison of action with language can be regarded as something akin tohistorical experimentation or hypothesis testing. In Pernick's study of anaes-thesia, he found that the 'calculus of suffering' - the social hierarchy of

40 Examples of this explicit focus on scientific practice include Frederic L. Holmes, ClaudeBernard and Animal Chemistry (Cambridge, Massachusetts, 1974); idem, Hans Krebs: The Formationof a Scientific Life (New York and Oxford, in press); Martin J. S. Rudwick, The Great DevonianControversy: The Shaping of Scientific Knowledge among Gentlemanly Specialists (Chicago andLondon, 1985); and Steven Shapin and Simon Schaffer, Leviathan and the Air-Pump: Hobbes, Boyle,and the Experimental Life (Princeton, 1985). Discussions of the changing attention to practice inthe historiography of science include Jan Golinski; 'The Theory of Practice and the Practice ofTheory: Sociological Approaches in the History of Science', /51s, 81 (1990), 492—505; DavidGooding, Trevor Pinch, and Simon Schaffer (eds.), The Uses of Experiment: Studies in the NaturalSciences (Cambridge, 1989); and Frederic L. Holmes, 'Do We Understand Historically HowScientific Knowledge is Acquired?', paper presented at symposium on 'Representing andUnderstanding the Natural World: Science in Western Culture', Norman, Oklahoma, 7 Septem-ber 1990.

41 Frederic L. Holmes, Lavoisier and the Chemistry of Life: An Exploration of Scientific Creativity(Madison, 1985), p. xvi.

42 Gerald L. Geison, The Private Science of Louis Pasteur, forthcoming, and Frederic L. Holmes,'Laboratory Notebooks: Can the Daily Record Illuminate the Broader Picture?', Proceedings of theAmerican Philosophical Society, 134 (1990), 349—66, and idem, 'Scientific Writing and ScientificDiscovery', Isis, 78 (1987), 220-35.

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sensitivity to pain that in principle governed how the newly discoveredanaesthetic agents should be used - was also confirmed in treatment.43 Practicematched medical principle. Yet such consonance between patient records andmedical texts does not always occur. Information from printed sources andclinical charts often confronts the historian with contradictions. In theeighteenth century, for example, Cullen repeatedly discouraged the use ofblisters as stimulants in fevers, in favour of tonic drugs. Yet a recent study ofsixty fever cases managed by Cullen at the Edinburgh Infirmary discloses thatwhile more than a third of the patients were blistered, a meagre five per centreceived tonics.44 Conversely, a prominent Boston physician claimed in an1839 medical journal that mercurial drugs had been 'given up almost entirelyin typhoid fever', while patient records from the Massachusetts GeneralHospital, where he practised, disclose that nearly a third of its inmatessuffering from the disease still received mercury.45 Assuming that thesephysicians wrote what they believed to be true, such discrepancies betweenthought and practice pose intriguing questions about the relationship betweenclinical experience and perception.

Discrepancies between the clinician's ideal and actual treatment of patients- the original concern of Ackerknecht's plea - underscore the historian's needfor caution in accepting medical rhetoric at face value. And recent work hasmade the correspondence between medical principle and medical practice lookeven more problematic than it did when he wrote. But there is also some riskthat, in systematically comparing practitioners' words with their deeds,scholars may be tempted to look at patient records as a vehicle for surprisingphysicians in the act of failing to practice what they preached. When languageand conduct do not correspond, this finding does not necessarily imply thatone simply belies the other. In many instances, the rhetoric is perhaps bestread as a statement of deeply held clinical ideas, commitments, and aspirationsrather than as a true mirror of bedside reality.

Focusing on this issue, two investigators set out to test claims made bynineteenth-century women physicians in America that they practised a lessinterventionist and aggressive medicine than their male counterparts, particu-larly in the management of childbirth. To assess how accurately suchideological pronouncements reflected clinical reality, they studied the patientrecords of two nineteenth-century Boston hospitals, one staffed by male andthe other by female physicians. The actual differences in clinical behaviourwere found to be negligible, certainly insufficient to warrant the characteriza-

43 Pernick, A Calculus of Suffering, pp. 171-95. More problematic is a study such as F. G.Gosling's Before Freud: Neurasthenia and the American Medical Community, 1870-1910 (Urbana andChicago, 1987), which assumes that its sample ofpublished case histories of neurasthenia representsa reliable cross-section of actual American practice.

44 Risse, 'Cullen as Clinician', and especially, 'Cullen on "Fevers": Models and ClinicalManagement', (forthcoming).

45 James Jackson, comments quoted in 'Report on Typhoid Fever', Boston Medical and SurgicalJournal, 19 (1839), 45-8, 53-60; and for comparison with actual clinical practice see Warner, TheTherapeutic Perspective, p. 315.

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202 Guenter B. Risse and John Harky Warner

tion of a distinctive women's medical practice. But, as both scholars con-cluded, the discrepancy between ideology and action emphasizes theimportant symbolic function of rhetoric. Claims of a 'feminine' approach topractising medicine reflected, aspirations and commitments that were import-ant to these clinicians, a difference in attitude if not in action that probablyhad an impact on the overall management of patients.46

One of the chief historiographic services patient records can perform is toclarify how particular medical concepts should be understood. There is simplyno way of precisely assessing the effective meaning of terms that characterizeclinical behaviour other than to determine the activity to which the termactually corresponded. One medical concept requiring periodic clarification isthe so-called 'healing power of nature', the inherent capacity for self-recoveryof the human organism. Traditional belief in this power suggested thatphysicians adopt a rather passive therapeutic stance that called for measuresdesigned to assist nature during its healing course. During the eighteenthcentury, Scottish physicians, for example, frequently expressed interventionisttendencies and distrust for the so-called 'powers of nature', while their medicalpractices were clearly dominated by the natural evolution of disease.47 Arevival of the idea that sickness should be simply left for nature to mendreappeared in mid-nineteenth century America. Patient files, however, revealthat even the most strident proponents of the healing power of nature adoptedan unmistakably activist plan of curing, vigorously prescribing such treat-ments as mercurial purgatives, opiates, and bloodletting.48 The correspond-ence between language and activity in patient records can teach historians howto read words more accurately in other media. In turn, by using patientrecords in comparing discourse and deeds, historians can develop an historicalglossary in which key words in the medical vocabulary of the past are givenoperational definitions.

The above example illustrates the changing nature of medical concepts andpractices over time, thus offering scholars another level of comparativeanalysis: the patient record itself is a revealing indicator of the changing natureof clinical mentality. Using patient documents, especially from hospitalswhere institutional continuity minimized variations in record format andinformation, provides excellent opportunities for ascertaining variable patternsof clinical behaviour. How different was the definition and management of

46 Regina Markell Morantz and Sue Zschoche, 'Professionalism, Feminism, and Gender Roles:A Comparative Study of Nineteenth-Century Medical Therapeutics', Journal of American History,67 (1980), 568-88.

47 See William Cullen, Clinical Lectures, Edinburgh, 1772-1773, M.S.S. Collection, Royal Collegeof Physicians, Edinburgh, pp. 359-60; and Francis Home, Clinical Lectures Delivered in the Year1769, taken by John Goodsir, Edinburgh 1769, pp. 10-24, also in the same manuscript collection.For a historical review of the healing power of nature concept, see Max Neuburger, Die Lehrevon der Heilkraft der Natur im Wandel der Zeiten (Stuttgart, 1926).

48 Warner, The Therapeutic Perspective, pp. 17—36; and see John Harley Warner, '"The Nature-Trusting Heresy": American Physicians and the Concept of the Healing Power of Nature in the1850s and 1860s', Perspectives in American History, n (1977-8), 291-324.

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'pneumonia' in 1850 as compared with 1890, and can any discrepancies beascertained in the clinical records? If so, how can they be explained?

A portrait of changing clinical behaviour across time simply describeswithout explaining or conveying historical meaning. Its interpretation must,again, be based in part on conventional textual sources. For instance, from anacquaintance with the published medical literature alone the historian canformulate reasonably detailed expectations about how clinical practice shiftedover time. Yet, when the patterns of change predicted on the basis of themedical literature and those discovered in clinical records significantly fail tomatch up, the discrepancy generates problems that invite historical attention.Could the variance perhaps reflect contemporary professional concerns notspecifically linked to the physiological actions of the therapy in question?

Therapeutic bloodletting offers a poignant illustration. Patient records clearlyshow that in American medical practice, bleeding diminished from the 1820sonward, falling off especially in the 1850s and 1860s. Yet many of the samepractitioners who came to restrict the practice persisted in maintaining thatbloodletting was perhaps the most important therapeutic agent at the commandof orthodox physicians. Indeed, they most fervently celebrated the importanceof bloodletting in principle at precisely the moment when it was all but vanishingfrom practice. One hypothesis suggests that bloodletting had taken on a power-ful symbolic significance for the orthodox medical profession as an emblem ofthe distinctive tradition that, in an egalitarian society, set it apart from thediverse groups of alternative healers competing for paying patients.49 Only by acareful comparison of the changing status of bloodletting in the medical litera-ture with its changing use at the bedside, can one discern its transformation frombeing an important therapeutic option to being only a key professional symbol.

The challenges to interpret inconsistencies between the published recordand clinical actions become even greater when the historian, through thesystematic study of patient records, discovers sharp, unexpected changes inclinical behaviour. For example, a sudden mid-nineteenth-century upswing inthe frequency of bleeding at one particular hospital must be explained, and anattempt made to identify the type of clinical situations in which the treatmentwas used. Did it replace other therapeutic modalities? The scholar must askwhether this was just a local matter, ascribable perhaps.to the pecularities of asingle attending physician, or did this anomaly exist in patient records fromother regional or national institutions? As has been suggested in this case, itmight represent part of a complex response by physicians to a crisis oforthodox professional power and identity that in turn directs the historian torather more substantive issues.50

49 Warner, The Therapeutic Perspective, esp. pp. 95-7, 125—32 on the use of venesection; JohnHarley Warner, 'Medical Sectarianism, Therapeutic Conflict, and the Shaping of OrthodoxProfessional Identity in Antebellum American Medicine', in W. F. Bynum and Roy Porter (eds.),Medical Fringe and Medical Orthodoxy, 1750—1850 ( L o n d o n , 1987), p p . 234—60.

50 John Harley Warner, 'Power, Conflict, and Identity in Mid-Nineteenth-Century AmericanMedicine: Therapeutic Change at the Commercial Hospital in Cincinnati', Journal of AmericanHistory, 73 (1987), 934~56.

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Conclusion

While a potentially rich source of medical information, patient records hardlyprovide a simple access to clinical reality. Most were written originally for thepurpose of documenting activities for which practitioners were individuallyresponsible. Reporting conditions and modes of treatment also facilitatedcommunication among various professionals engaged in the business ofhealing. Often the information was needed for administrative purposes, tocompose reports, financial statements, and institutional statistics. Finally,medical educators employed individual patient records in their clinical teach-ing. And, since the turn of the century, the clinico-pathological conferencehas been a central component in the education of medical students, residents,attending physicians, and even journal readers.

The clinical chart reflects the perceptions and interpretations of contempor-ary health care providers, including physicians, nurses, students, and others.The patient history can vary considerably since it reflects the impressions ofthe individual medical observer with a unique level of understanding, com-pulsion, and skills. Perception and understanding were moulded not only bythe biological and social realities of private practice, hospital life, andpatienthood, but by immersion in contemporary medical belief systems. Inturn, diagnosis was assigned with reference to contemporary nosologicalschemes. Investigators should be cautious in interpreting such diagnosticlabels and must recognize that the recorded observations actually held meaningonly within such schemes. As narratives, not mere chronicles, clinical casehistories already contain built-in analysis and interpretation.

Considering the shifting nature of clinical interpretations over time, clinicalfiles, like other sources of historical information, need to be approached witha great deal of care. A researcher must be cautious with reconstructions basedon the study of individual cases, since they could become the basis forunwarranted conclusions. Also, the very novelty of the case record as anhistorical source places it at risk of becoming the foundation for yet anotherform of fashionable antiquarianism. Some accounts are detailed and organized,others flippant and casual, while progress notes were often neglected, abbre-viated, or even invented. More important, one cannot assume that the actionsspecified in such records were consistently executed and represent all of theevents experienced by patients and perceived by medical personnel. Indeed,instances can be discovered where common clinical situations went unnoticed,and many charts and case books plainly omitted errors or changes in theadministration of drugs. One particularly difficult phenomenon for thehistorian is to detect in older documents the precise point when medicationwas discontinued.

In spite of such necessary caveats, the use of patient records provides uniqueopportunities for historians of medicine. Neither ideology nor behaviour canbe fully understood without a knowledge of the other. What physicians saidand what they did, their medical ideas and their social interactions with

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patients, are best investigated together. Documented changes in medicalknowledge and practice at the institutional level can become agents forstudying larger questions of social change, medical epistemology, clinicalcreativity, and the parameters of clinical decision making. Studying patientrecords may well become one vehicle for an historiographic synthesis inwhich artificial distinctions between the intellectual and social dimensions ofmedical experience are dissolved.

Acknowledgements

We are indebted to Roy Porter, Julia Sheppard, and Jack Pressman forsuggestions and comments regarding this paper.

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