Patient Case Records In Medical And Family History: Examining The Records Of The Royal Free Hospital

Abstract

The purpose of this article is to highlight the value and potential of patient case records as an historical source. Previous histories of the hospital (and of other healthcare providers more generally) have neglected to consider the patient. This is partly as a result of the ‘history from above’ approach of past histories which have focused on the founders and medical staff of such institutions and never on the people who were treated. During the early 1990s Porter called for the patient to be brought into the focus of medical history, and Risse and Warner drew attention to patient case records as a means of doing so. In the near twenty years which has passed since, however, patient records have still not been utilized by historians and the patient remains largely absent from history. By using the project ‘Royal Free Hospital Patient Case Records’ as a working example, this article will illustrate the benefits of using these records as a source as to patient identity, experience of medical treatment, use of the medical market, and life-cycle of individual, family, and community ill-health.¹ The type of information the historian can extract from patient case records will be discussed and the example sampling method explained. The wider use and potential of patient records in history will then be considered and some practical advice given to help prepare historians to use such records to fill the void that is the history of the patient.

The History of the Patient

Bynum has suggested that in the history of twentieth century medicine only two types of patient have been discussed, ‘patients who contributed to medical discovery by having a peculiar condition or by being the first to receive a new diagnosis or therapy; and the great and good of history, whose ills historically inclined doctors viewed through what they call the “retrospectroscope” (Bynum 1994: 208). Similarly, Digby has claimed that the historiography of women as patients has focused either on ‘clinical progress, heroic endeavours of male doctors, and ensuing benefits to women’ or on ‘the sexual politics of sickness and the exploitative, self-interested nature of doctors’ interventions’ (Digby 1994: 259). As a result of these types of histories, patients have tended only to have been discussed in relation the ‘great men’ of the hospital, and have not been the focus of their own history (Porter 1992; Porter 1993). We know very little about patient identity and the conduct of the relationship between the patient and the practitioner in the hospital setting since the eighteenth century. The nature of patient admission, treatment, discharge, and their experience of institutional confinement remains a mystery, as hospital histories have ignored the prominent issues that resulted from hospitalisation, namely ‘dependence, depersonalisation, and isolation from family networks’ (Risse 1987:175).

In 1992 Porter claimed that patients were not ‘subhistorical’, timeless objects merely waiting to be treated by doctors who are part of progress’, but deserved a history in their own right (Porter 1992: 91). By 1994 Bynum claimed that the ‘process of trying to recapture what it was like to be a more ordinary patient has now begun’ (Bynum 1994: 208). Since that time, however, the work of only a small number of historians has addressed specific groups of patients in history since the eighteenth century. Shorter and Digby have both drawn attention to women and children as patients (Shorter 1993: 109–114; Digby 1994: 259). Shorter claimed that in the nineteenth century women and children started to see the doctor for the first time (Shorter 1993: 109–10). These patients were so numerous that they became the ‘keystone of modern medical practice’, a point echoed by Digby who emphasised the importance of the expanding field of gynaecology to women patients during the nineteenth century (Digby 1994: 254; Shorter 1993: 110). Other historians have used case studies as a means of bringing the patient into the focus of history. In Risse’s discussion of the medicalisation of the hospital, he reconstructed the ill-health experienced by a tailor in the late eighteenth century (Risse 1999: 257–9). The interaction between 27-year-old Johann Duschau and the hospital is one of the only attempts in the historiography to personalise the patient in order to understand the choices people made in regards to their medical care. Jacyna has discussed the transmission of medical knowledge from professional to lay contexts by using the example of James Scott, a 34-year-old Edinburgh accountant, who sought treatment from various consultants for loss of strength in his limbs (Jacyna 1992: 255). Through this case study, Jacyna focused on the expectations of the patient when seeking out medical care in the early nineteenth century, during a period when medical knowledge ‘formed part of the common culture of gentlemen’ (Jacyna 1992: 257). Jacyna argued that the physical examination was not simply a tool of medical intrusion and power, but was a means of diagnosis thought credible by the patient, and one they expected to be performed on them as part of a thorough examination. Although all of these studies are arguably quite specific to time and place, it stands to reason that the more patient histories that are compiled, the more we can learn about patients. As Bynum has stated, ‘Being a patient was (and is) an experience with identifiable universal features’ (Bynum 1994: 209).

Beyond these few works of the early 1990s there has been little attempt to bring the patient to the forefront of medical history (Gillis 2006). Indeed, Digby stated in 1999 that we ‘still know relatively little about sickness behaviour in the distant past — the characterization of illness, the preferences of sufferers, and conventions governing behaviour’ (Digby 1999: 224). We know equally little about how and why patients made use of medical provisions throughout their lifetimes, both in conjunction with one another at times of ill-health, and at distinct ill-health intervals. In turn, whilst it is accepted that more work must focus on rediscovering the patient in history, the comprehensive use of patient case records for this purpose has been minimal (Reinarz 2008; Riha 1995; Risse and Warner 1992). It is these lacunae that the current article seeks to address.

The Use of Patient Case Records

Hospital patient records offer the medical and family historian an abundance of information regarding patient identity, health and disease, medical consumer choices, medical and surgical hospital practice, and patient experience of the hospital. The aim of the project on which this article is based — ‘Royal Free Hospital Patient Case Records’ — was to examine these themes in relation to the patients of a central London voluntary hospital during the early twentieth century. The Royal Free Hospital (henceforth RFH) was founded in 1828 as a small out-patient dispensary, but had grown to a general voluntary hospital of modest size by the early twentieth-century, having treated around 2,500 patients annually from its site on Gray’s Inn Road (Royal Free Hospital Archive, hereafter RFHA: The Eighty-Sixth Annual Report: RFH/1/2/2: 18–19). Founded on the principle that no patient would require a subscriber’s letter of recommendation to enter the hospital, theoretically ‘poverty and sickness’ were the only requirements needed to receive free medical treatment at the hospital (The Eighty-Third Annual Report: RFH/1/2/2: 10).

The personal information contained in patient records provides the historian with a unique insight into the identity of hospital patients. They contained the patient’s name, sex, age, marital status, occupation, and residence, and will sometimes also have included the patient’s nationality, race, and religion (Risse and Warner 1992: 185). The date of admission and discharge were included as standard, as was a history of the patient’s illness. The patient case records of the RFH indeed encompassed personal details as to the patient identity, their current illness, health histories of both the patients and their families, and a treatment history, with the presiding practitioner clearly identifiable (see Figure 1).

Figure 1. Patient Case Record of William Armsley: Dr Carr: Admitted 5^th June 1907 Royal Free Hospital Archives.

The nationality, race, and religion of the patients at the RFH were not recorded as standard, but this information does often appear in the patient histories or daily treatment notes. The formality with which the patient’s name was noted in a case record can tell the historian something about their social status or indicate what kind of a relationship they held with the hospital. If studied as a collective sample, the age, sex, and marital status of the patients contained in hospital records provides the basis for identifying the average, or most likely type of person to make use of the hospital in question. The occupation of the patient reveals much about the likely class, or social or financial standing of the people turning to the hospital for medical treatment. The address of the patients is telling as to the relationship between the hospital and its local community, and to its appeal to those willing to travel long distances for treatment.

Historians can also use patient records as an indication as to the health of a population at the time of their completion. The health of the London population is a seriously understudied area of medical history. Estimations regarding the extent and pattern of ill-health and disease during the past (such as those relating to epidemiological transition debates) have been compiled through the use of mortality figures, meaning that most represent only what the population was dying of and not what they were suffering from throughout their lifetimes (McKeown and Record 1962). The early twentieth century records of the RFH contain the current ailments of the patients, as well as personal and family health histories, which give a unique insight into the lifecycle of ill-health of the London population in the years between the end of the nineteenth century and the First World War. Moreover, as Risse and Warner have explained, the patient histories contained in case records provide an insight into the patients’ perspective of their own illness. Histories provide ‘a unique record of popular health beliefs among lower-class patients, notions of disease causation, and chronicles of self-help practices’ (Risse and Warner 1992: 190).

The medicines, treatments, and surgical practices applied to the patient whilst in hospital can also be analysed based on the information obtained from the daily and surgical notes contained in the records. Historians such as Porter and Shorter have detailed some of the examination techniques of the doctor in the nineteenth century, including those of percussion, palpation, and the taking of blood pressure, but the historiography lacks any examination into the patient case records of hospitals in order to see the extent to which these techniques were actually performed on a routine basis (Porter 1993: 179; Shorter 1993: 81–4). Nowhere else can the practical application and development of hospital medicine be analysed in greater detail than through the use of patient records. The records of the RFH include detailed accounts of patient treatments, including both those used in the process of diagnosis and those performed throughout the remainder of the patient’s stay at the hospital. This information provides an insight into the development of hospital medicine at the turn of the twentieth century, as patients underwent treatments ranging technically from the use of leeches to x-rays, and were prescribed medicines and drugs ranging from mild dietary and herbal remedies to those of much stronger prescription, such as heroin and cocaine. Not all hospital records will show such contrasts in medicine and treatments, but they nonetheless provide a rare snapshot of the care afforded the patient at that particular institution. If used in contrast to each other, patient records from different hospitals could be used to build a detailed picture of the application and transitions of hospital medicine throughout the last few centuries.

The experience of being a hospital patient can also be drawn out from patient case records. Risse and Warner claimed that hospital patient records provide a picture of the ‘texture of hospital life’, such as by recalling the contact between physicians or medical students and the patients, visits from family and friends, the diet provide whilst on the wards, and the experience of the ‘recovery or dying’ of patients more generally (Risse and Warner 1992: 190–1). When used alongside information regarding the medicine and treatments patients received in the hospital setting, the patient records provide a personal window into hospital life which cannot be obtained elsewhere. Further information that can be extracted from the patient records, including the length of patient stay at the hospital, could be used in conjunction with other hospital records to create a broader picture of hospital life for patients from admission to discharge and after. In the case of the RFH, the rules and regulation of the hospital, visitors’ reports, and almoners’ reports all exist for the early twentieth century. Through the reconstruction of the patient experience of hospital life, patient case records allow us to assess whether the hospital from which they were taken was typical in the treatment it provided patients, and the extent to which the patient experience differed between such institutions.

Case records also allow the historian to identify how patients made use of a particular hospital in relation to the wider medical marketplace. Patient histories detailed the previous means of medical assistance the patients and their families sought in their lifetimes, including other institutions, dispensaries, general practitioners, or means of self-help. Such information allows for the hospital in question to be placed in the wider medical community during the period of the records under examination, and provide a rare and valuable insight into how people made use of available medical provision. We cannot expect to understand the history of medical practice without including the choices of medical care made by the individuals who would be its patients. The reasons behind how patients came to decide where to seek medical treatment had a profound impact on the changes and developments experienced by the medical profession over the last two centuries. While many patients decided to seek treatment at a specific hospital, others had no choice in the matter (such as the inmates of a local correctional facility to the RFH, who were brought to the hospital when in need of medical treatment).

How Patient Records Can Be Sampled

In order for a group of patient case records to best represent the institution from which they were compiled, a well structured sampling method is essential. Whilst the front cover page of most nineteenth and twentieth century hospital records typically contained the same basic patient information (see Figure 1), the remaining pages of a case record could vary dramatically in length and detail. A fair sample is the only way to combat potential bias towards more interesting cases, or those which might better reflect the argument or opinion of the historian conducting the study. The process of sampling patient case records depends on the availability of the records and on the project aims of the historian. The best place to go about an initial search for hospital patient case records is through the National Archives website, from which individual archive collections can be located.² In some instances, usually in smaller collections, the individual records will be listed in an archive catalogue. More often, and particularly in larger collections, patient records will be catalogued by date range and the attending physician under which they were recorded. In these instances the numbers, quality, and detail of the records cannot be known until either the archivist is contacted or the records have been examined in person by the historian. It should also be remembered that there is theoretically a one-hundred year block protecting medical records in the United Kingdom.

The methodology used in the project ‘Royal Free Hospital Patient Case Records’ provides a relevant working example of how such patient records can be sampled. The RFH archive currently holds substantial numbers of patient records. There are over 250 volumes of records each containing approximately 500 pages of record material. The records have been stored firstly by the attending physician or surgeon, then by the sex of the patient being treated, and finally by the date the patient was discharged. The project made use of a sample of 480 of these case records selected according to a four tiered sampling method; by staff member, year, season, and patient sex. Such a complex sampling method might not always be possible when using the patient case records of other institutions, as sufficient numbers of records may not survive or records may not have been stored in a system that allows for such sampling. If records are found not to be organised to such a degree, the historian should only use the relevant sample tiers of this example.

The RFH project sampled the patient records of four male staff members; two surgeons and two physicians. These staff members are the physicians H. Sainsbury and J. W. Carr, and the surgeons J. Berry and E. W. Roughton. The records of these staff members were chosen for the project as these men held the general medical and surgical positions at the RFH, and so their records should best represent the wide range of cases treated at the hospital. In addition their records survive in large numbers for the early twentieth century, which is a crucial factor for this study. An equal number of 120 records were sampled from each staff member, meaning that half of the sample represents surgical patients, and the other half medical patients. This was an important aspect of the sampling process, as the project aimed to analyse the treatment methods of both physicians and surgeons, and explore the experience of both medical and surgical patients at the RFH. The exclusion of the records of a female member of staff was a deliberate choice, as the records of female staff members do not survive in sufficient numbers at the RFH to conduct a fair and representative comparison. Moreover, the study would have had to consider not only the relationship between the male member of staff and male and female patients, but also that of a female member of staff to her patients, which it was decided would have proved too broad an examination for the project alone to conduct.

A further aim of the RFH project was to examine the hospital patient in the years between the end of the Victorian era and the First World War. This meant that the project sample needed to be statistically significant in size and stretch across a significant time frame. To best represent the early years of the twentieth century, it was decided not to sample the records of one single year, as this would have given a cross section of the hospital patient base at one instance and not represented the patient base over the course of a substantial time period. Instead, the sample years of 1902, 1907 and 1912 were chosen. However, whilst the archive catalogue states that records survive, for example, in the case of the surgeon Mr. Roughton, from the years 1891–1912, the records were found not to exist in a complete series running throughout these years, but for only certain random and inconsistent periods within this timeframe. This meant that the project needed to find years between 1900 and 1914 for which the records of all of the desired staff members survived. It was also important that the project sampled records by season in order to gain an understanding of seasonal medical complaints and disorders suffered by hospital patients. Equal numbers of forty records per staff member were sampled from each year 1902, 1907 and 1912. This number was split equally between records of summer months, and winter months in each year. The records survive bound by discharge date, and so twenty records were sampled starting from the discharge date of 1 July, and twenty winter records from the discharge date of 1 December for each selected year.

The final aspect of the sampling method developed for the RFH project was that overall half of the records sampled would be that of male patients, and half of female patients. This meant that ten male and ten female patients were sampled per season, per year, per staff member. The reason for the equal number of male and female patients sampled for this study was twofold. Predominantly this decision was one of practicality, as the surviving records have been bound by patient sex. However, as one of the main aims of this project was to gain a better understanding of the ill-health suffered by the male and female population during this period, and an insight into the experience of both male and female patients at the hospital, it was decided that a sample which included equal numbers of male and female patients would best serve these aims.

Quantitative analysis of the contents of the patient case records enabled the project to calculate the average and most common patient age, marital status, occupation, and the distance travelled from their place of residence to the RFH. Such analysis was also conducted into the ailments contained in the records, and allowed for the project to calculate the most common injuries, diseases, and complaints treated at the hospital. Of course the large number of surviving patient records of the RFH allows the project to sample large numbers of records and conduct large scale quantitative analysis, which other such projects might not be in the practical position to repeat. In smaller samples, qualitative analysis of patient records can provide an abundance of equally important information regarding the hospital patient. Qualitative analysis of the patient histories contained in the records allowed the RFH project to speculate as to the financial circumstances of many of the patients by considering and comparing such details as the patients’ living conditions, previous treatments, and travel histories. Furthermore, case studies are an excellent means of discussing in detail those patients who represent either the typical or non-typical patient base of the hospital, and those who appear in the sample of records on more than one occasion.

The Wider Potential of Patient Case Records as an Historical Source

From a sample of patient case records like that of the RFH project the historian can collect an abundance of information to help place the patient in the current historiography. Whether that information relates to the patient identity, health history, experience of hospital life, or their consumer choice of medical care, it would subsequently place the patient at the forefront of medical history for the first time. In addition, the family network of patients can be recognised and assessed. The contact and experience of ill-health in the family and the wider community is an everyday occurrence, yet this is rarely acknowledged or examined in the current historiography. As any serious reference to the patients themselves in the current historiography is novel, it is hardly surprising that any deeper analysis into their family networks has never been performed. Patient case records can provide a window into how families experienced and dealt with ill-health, both as individual members and as a unit.

Whilst the patient case records provide a wealth of information about the patients themselves, they can also be used to expand our understanding of wider areas of the historiography. From records like those of the RFH, the historian can not only learn about the patients, but also the physicians, surgeons, and other staff members treating the patients of the hospital. The techniques and medicines favoured by the presiding staff member of a case record can be assessed and compared. By sampling records by year and season, the main health issues of these different times can be assessed. Harsh winters, a bad urban fog, and disease outbreaks are some of the environmental factors that patient case records can help to identify. Examining records from across a significant time frame also allows for the techniques and technologies of hospital medical care to be tracked. Depending on the timeframe from which the patient records date, the technologies will of course differ. In those records of the RFH some treatments can be seen to wane over the course of the sample years, while the use of others increase at a pace, such as the use of x-rays. Moreover, if patient records are examined by sex, as in the RFH example, much can be learnt regarding the beliefs of the causes of ill-health in each sex and how it was believed each sex should be treated in the hospital setting as a representation of wider gender differences in society.

Patient case records show even wider potential as an historical source when used in conjunction with other records. By examining the contents of patient case records with other contemporary sources, such as different hospital records, medical textbooks, journal articles, and newspaper reports, a more detailed understanding of hospital medicine can be compiled. In the case of the RFH project, patient case records are used alongside financial records, annual reports, committee minutes, correspondence, and newspaper reports in order to construct the general history of the institution for the first time. These records can be used in conjunction with rules and regulations, almoners’ reports, Chaplaincy records, and nursing and Matron records in order to reconstruct the daily routine of the patients treated at the RFH. Many hospitals were also linked to charitable organisations and funds, such as the Samaritan Fund and the Dresden Assistant Fund at the RFH (set up with funds left in the form of a legacy to the hospital), the records of which are a valuable source in our understanding of the relationship between the patients in the case records and the hospital in the wider community. Contemporary textbooks are a useful source for examining what medicines and treatments were being taught and advised in the medical community, but it is only when they are used in conjunction with patient case records that the historian can compare the contents of these texts to the medicine and practice reportedly being undertaken in the hospitals themselves. We can also compare patient case records with census returns for the institution from which the case records are taken. This comparison allows the historian to assess how representative the sample of case record and the census returns were to one another, and thus to the wider community.

Advice for Using Patient Case Records

As an historical source, patient case records have the potential to introduce the patient to the history of medicine on a large scale, but as with any source, care must be taken when sampling, transcribing, and analysing. Transcribing patient case records might not always be considered a necessity, but the process and the end result are very useful tools of analysis. The process of transcribing means that the records are read thoroughly and any difficult handwriting deciphered. Patient records can vary in length from only a cover page to tens of pages, and so to transcribe large numbers of them can be time consuming. One effective way to transcribe records effectively is to recite their content into a voice recognition programme. This method will shorten the transcription time and ease the discomfort caused by typing for long periods.

When sampling patient case records, we have to consider how they have been arranged and saved, which will differ between each collection. While records for institutions including the RFH survive in large numbers, it is often the case that collections are quite random in the dates and staff members of which records have been kept. An archive catalogue may report that patient records of individual staff members survive between two dates, but often this does not mean that they survive in a complete run between those dates. This is why it is imperative that the historian examine a patient case record collection and not assume that they survive for the time period or staff member they require. In many instances patient case records will have been bound together for storage purposes. This is the case at the RFH, where records have been bound and stored in boxes of up to 500 pages of material according to the physician’s or surgeon’s name printed on the cover page. Whilst binding the records by the presiding staff member is an obvious way of organising such records, the historian must be aware that in some instances the staff member name printed on the front cover of patient case records would not have been the staff member presiding over the patient’s case. This information can more usually be gained from within the record, which will state at its beginning the reason for the patient’s admission, and the staff member whom the patient was to be treated under. It is also important to recognise if the case records have been bound by date. At the RFH, the case records were bound by the assumed presiding staff member and by the date the patient was discharged from the hospital. Such organisation may cause problems for the historian wanting to examine trends in patient admission. One means of combating this may be to use the sampled case records to calculate the average length of stay of patients at the hospital in question. At the RFH, the average length of patient stay was found to be one month or under, which meant that seasonal admissions trends and health comparisons could still be drawn.

When using any patient case records, it is important to consider the circumstances in which they were created. Patient case records of hospitals, particularly those of busy hospitals such as the RFH, would often not have been completed by the attending physician or surgeon themselves. In most cases, a clerk, medical officer, or nurse would have contributed to the record over the course of the patient’s stay at the hospital. In the patient records of the RFH, the medical staff were always referred to in the third person and there are no signatures included to represent the individuals responsible for completing the records. It is apparent that the handwriting within individual records often changes many times over the course of the patient’s stay, indicating that many different members of the hospital staff made contributions to the contents of the records. Much can be learnt from the tense used in the records as to how and when the records were compiled. In some parts of the records, usually the patient’s present condition and past health history, the tense used often indicates that the staff member completing the record was present with the patient, referring to their appearance and condition in the present tense and inserting direct quotes from the patient into the record. Equally, many of the daily notes included in the records refer to the current appearance and treatment of the patient. The tense contained in the language of the records is important to consider when assessing the contact held between the patient and the members of medical staff. The present tense contained in the records indicates that the patient was often present when the record was being compiled; a detail which is crucial when attempting to understand the relationship held between the patient and the medical staff of the hospital.

Conclusion

This article has aimed to demonstrate the potential of patient case records as a means of bringing the hospital patient into the history of medicine. Historians have acknowledged the lack of attention paid to the patient throughout history, but little work has attempted to address the issue. Subsequently, for all we know about the history of hospitals and the medical profession, we still know relatively little about the patients on which the profession depended. Risse and Warner’s article was the first to recognise the potential of patient case records up to this point, but the continued lack of attention paid to patient case records as a source in medical history suggests that they have once again been forgotten or dismissed as a viable source. Such dismissal has come from Bynum, Fissell, and Laurence, who have claimed that case records may be a poor reflection of bedside encounters between patient and practitioner, as they only represent the ‘doctors’ versions of the doctor-patient encounter’, by containing the structured and methodical means of questioning and physical examination undertaken by the practitioner (Bynum 1994: 209; Fissell 1991: 152; Lawrence 1996: 23). Drawing the patient out of a source originally compiled by medical staff is of course a difficult task, but so much can be learnt from patient case records irrespective of the fact that they were not compiled by the patients themselves. Patient identity, information on patient health and health history, medicines and treatments patients experienced both in the hospital and previously, and how the patients made use of the hospital as a part of the wider medical market is just some of the information that can be learnt from patient case records. If these records are linked to other sources, they could help to provide alternative hospital histories which place the patient and their families at the forefront of history for the first time. It is extremely rare to find sources such as diaries or correspondence written by the patients themselves which refer to their time in hospitals and describe their care and treatment, which is all the more reason for historians to draw out all the patient information they can from patient case records.

The sampling process and methodology use in the example RFH project is of course only one means of using patient case records, which has been developed for the specific aims and purpose of that study. Much can be learnt about the medical profession from the records it kept and none are more personal or more telling as to the relationship of the patient and the hospital than patient case records. The manner in which the profession methodologically recorded personal information about its patients is a testament to both the scientific development of medicine over the course of the eighteenth and nineteenth centuries, and to the apparent trust and dependence on the system on the part of the patients, who gave up personal details with the expectation that modern hospital medicine would alleviate their ills. Though written by medical staff and not a source received directly from the patients’ themselves, patient case records represent the point of contact between the patient and the practitioner, and are therefore one of the historian’s closest means of recapturing the patient in history. Patient records exist for many medical institutions in Britain from across the previous two centuries and it is hoped that historians of medicine will begin to recognise their full potential as a source of medical history, and make use of them accordingly.

Biography

Biographical Note

Lynsey Cullen is completing a PhD on patient experiences at the Royal Free Hospital in London. lynsey.cullent@brookes.ac.uk