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Research method

Patient Case Records

Patient case records are the files institutions kept on individual patients: admission notes, case books, diagnoses, treatments, lengths of stay, outcomes, and sometimes letters written by or about the patient. They yield evidence of how a hospital or asylum categorised and treated people and, read in bulk, of who was admitted and what staff recorded about them. Historians either code large series of files to find patterns or read single files closely for what a patient managed to say.

Historians of asylums and hospitals reach for case records when they want to move from what institutions claimed to what they actually did with patients, and when they are looking for patient voices that other sources omit. Coding hundreds of files can show which diagnoses, symptoms and outcomes dominated; reading one file can show a patient contesting the doctor's account. The central limitation is that the record was written by staff: patient speech is mediated by the doctor's gaze, some groups are under-counted, and the file shows how a case was recorded and treated rather than the underlying truth of the illness.

Studies

5

Findings

6

9 supporting · 0 challenging · 0 qualifying citations

Open tensions

2

Currently

What we know

  1. Coding a full series of case files reveals patterns invisible in single cases. Linden and Jones coded biographical data, service history, symptoms, diagnoses and outcomes for 462 of 1,212 military admissions to the National Hospital from 1914 to 1919, finding motor and sensory loss dominant, psychogenic seizures about 3.5 times rarer than in Berlin, almost no malingering labels, an average stay of 69 days, and 83 percent privates. Labels shifted from shell shock toward functional disorder and, by 1918, hysteria.
  2. Patient speech in the file is usually mediated by the doctor's gaze, but letters preserved in or alongside case files can break through. Richard Lea's twelve letters insisting he was sane name individuals, describe transfer among 'murderers' and document race and illegal detention in the Cape network. The Brompton almoner-patient letters are a unique collection of patient voices otherwise missing from medical history.
  3. Records expose how race and class governed treatment. At the Cape, moral therapy meant recreation for paying white patients and heavy labour for Black patients. At Morningside, fee tables for the East and West houses show class splitting libraries, fees and space even within a regime of patient writing.
  4. Aggregate patient statistics show pressure on the whole confinement system. Lunacy Commission figures for Victorian Lancashire show the county asylum population quadrupling in forty years to 1901 while workhouse insane numbers barely rose, leaving chronic cases in expensive asylum beds; Irish-born residents nearly doubled to over 191,000 by 1851.
  5. Case files record how an institution classified and treated, not what was biologically true. The National Hospital files cannot settle organic versus psychical aetiology, only how Queen Square recorded and managed cases, and no follow-up proves that recorded improvements lasted.

Largest unresolved question

Scale trades against voice. The 462-file coded series can quantify symptom profiles and lengths of stay but treats each patient as a set of staff-recorded variables; the single Lea file gives a patient's own words at length but is, as the authors say, one literate English-speaking patient's file and not a representative survey of Cape inmates.

Common misconceptions

  • Case records tell you what was actually wrong with the patient.

    They tell you what the institution recorded and did. Linden and Jones state that the National Hospital files cannot settle organic versus psychical aetiology, only how Queen Square recorded and treated cases, and that the diagnostic label itself shifted over the war years.

  • A case record is the patient's own story.

    Most case notes are doctor-centred and patient speech is mediated by the doctor's gaze. Lea's file is unusual because it contains twelve letters in his own hand, and even then the authors read them against institutional practice rather than as a transparent account.

  • A large series of files is representative of everyone the institution treated.

    Series have systematic gaps. Officers are under-counted in the National Hospital files because they went to separate hospitals and private notes were lost. In Victorian Lancashire, workhouses could legally keep non-dangerous cases of unsound mind, so asylum files alone miss part of the pauper lunatic population.

  • An outcome recorded at discharge shows the treatment worked.

    Discharge notes end when the file ends. With no follow-up, nothing in the 462 files proves that recorded cures lasted, so outcome fields measure the institution's judgement at one moment rather than recovery.

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