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Reconstructing Clinical Activities: Patient Records in Medical History

*Department of History of Health Sciences, University of California at San Francisco 533 Parnassus Avenue, Room U-464, Box 0726, San Francisco, California 94143-0726, USA
Section of the History of Medicine and Life Sciences, Yale University School of Medicine L130 SHM, P.O. Box 3333, New Haven, Connecticut 06510, USA
SUMMARY The past decade has witnessed growing interest among historians in the use of patient records as one source of information about the medical experiences and perceptions of the past. Drawing examples from studies that employ what are variously called clinical case histories, clinical charts, and patient notes, this essay draws attention to some of the historiographic possibilities and problems of using patient records. Such documents provide one basis for tracing shifts over time in clinical pratice, perceptions as well 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 conjuction with other kinds of texts, for comparing clinical ideas with clinical activities, and thereby for exploring the relationship between ideology and behaviour. The opportunities patient records offer to historians of medicine are substantial, but the paper cautions against the assumption that these sources provide somehow privileged access to clinical reality
Keywords: age; case histories; class; clinical chart; clinical pratice; ethnicity; gender; geography; hospital; patient records
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