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The Clinical Record in Medicine Part 1: Learning from Cases* Stanley J. Reiser, MD, PhD
1 he clinical case record freezes in time that episode in life called illness. It is a story in which patient and family are the main characters, with the doctor serving a dual purpose as both biographer and part of the plot. The content of this biography varies greatly, reflecting its many purposes: to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions. In this essay, I discuss how clinical cases have shaped and reflected learning and action in medicine and how the document in which these cases are inscribed—the clinical record—has influenced medicine. Cases and Records in Hippocratic Medicine Like other important developments in Western medicine, the clinical record was advanced significantly in Greece in the fifth century B.C.E., when medical practice was dominated by Hippocrates and his disciples. Case records in the Hippocratic literature have two basic functions: to demonstrate the natural causes of illness and to portray the clinical course of illness through accurate observations of the patient's symptoms. The pursuit of this twofold task required doctors to be open and honest regarding the outcomes of the treatment they administered. The integrity of the record is evident in the Hippocratic cases, for in many instances the patient dies. The format of the Hippocratic case record is chronologic. First, preceding causes and presenting symptoms are documented, as in the case of Apollonius in Abdera (1). Apollonius "was ailing for a long time without being confined to bed. He had a swollen abdomen, and a continual pain in the region of the liver had been present for a long time; moreover, he became during this period jaundiced and flatulent; his complexion was whitish." Next, we learn of the actions and symptoms that bring the patient to seek care. After dining one day and drinking to excess, Apollonius "at first grew rather hot [and] he took to his bed." "Having drunk copiously of milk, boiled and raw, both goat's and sheep's, and adopting a thoroughly bad regimen, he suffered much therefrom." Reports on the progress of the illness follow. These are not written daily, but at times when important changes in symptoms occur, as in the following: A version of this essay was presented at a symposium, "The Medical Journal: Past, Present, and Future," held in honor of Edward J. Huth, Editor of Annals of Internal Medicine, on 14 September 1989. Dr. Huth retired as Editor on 30 June 1990. The papers from the symposium will be published in a Festschrift in his honor. * The second part of the article focuses on twentieth century improvements in the content and purpose of the case record. It will appear in the 1 June 1991 issue.
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There were exacerbations of the fever; the bowels passed practically nothing of the food taken; the urine was thin and scanty. No sleep. Grievous distension; much thirst; coma; painful swelling of the right hypochondrium; extremities all round rather cold; slight delirious mutterings; forgetfulness of everything he said; he was not himself. About the fourteenth day from his taking to bed, after a rigor, he grew hot; wildly delirious; shouting, distress, much rambling, followed by calm; the coma came on at this time. . . . About the twenty-fourth day comfortable; in other respects the same, but he had lucid intervals. He remembered nothing since he took to bed. But he quickly was again delirious, and all symptoms took a sharp turn for the worse. About the thirtieth day acute fever; copious, thin stools; wandering; cold extremities; speechlessness. The Hippocratic cases generally conclude by disclosing the result, which is often, as in the case of Apollonius of Abdera, given starkly: 'Thirty-fourth day. Death." The chronologic ordering of events in these case records reveals the Greek concern with therapeutic timing. To the Greeks, deciding when to use an intervention was as important as deciding what intervention to use, for a particular remedy was thought to have a different effect depending on the stage of the illness in which it was given. Chronologic portrayal also focused attention on the symptoms most predictive of outcome. The Hippocratic physician used this prognostic power to decide which cases to accept or decline. This action had its origin in a fundamental tenet of Greek medicine of this period, namely, that futile therapy should not be used. To pursue a treatment that could not succeed not only harmed the patient but diminished the standing of the practitioner and the reputation of medicine itself. This viewpoint, which has an uncanny bearing on modern medical practice where much anguish often attends decisions to withdraw or withhold therapy, is stated eloquently in the Hippocratic essay "The Art" (2): I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless. . . . For if a man demand from an art a power over what does not belong to the art, or from nature a power over what does not belong to nature, his ignorance is more allied to madness than to lack of knowledge. For in cases where we have the mastery through the means afforded by a natural constitution or by an art, there we may be craftsmen, but nowhere else. Prognostic learning and insightful therapeutic timing were perhaps the most important skills a Hippocratic physician could have. The case history, by its revealing chronology of illness, furthered their attainment.
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Role of Clinical Cases in Creating Disease Categories The use of case records to uncover fundamental knowledge about illness was greatly furthered in the seventeenth century through the work of Thomas Sydenham, called by admirers the ''English Hippocrates." In his time, symptoms were generally not classified into entities called diseases (although epidemic disorders were named). Rather, physicians of this era attributed sickness to a single causal mechanism that had been recognized at least since Hippocratic times—disruption of the equilibrium of the body's four main building blocks or humors (blood, phlegm, black bile, yellow bile). The basic illness therefore was humoral disruption. When this occurred, the result of initiating pathologic factors such as climatic changes or excessive consumption of food or drink, different symptoms expressed the new proportions of the relation among the humors. Sydenham began to recognize similarities in the patterns of symptoms of the patients he treated. Living in an age when the classification of plants and animals received much attention, Sydenham showed the influence of this intellectual climate when he hypothesized that illnesses might have tangible forms that could be classified by the unique conjunction of their characteristic symptoms, just as plants could be classified by their characteristic features: "It is necessary that all diseases be reduced to definite and certain species and that, with the same care which we see exhibited by botanists" (3). Sydenham's great contribution was to synthesize from clinical records the case histories of individual patients into a disease history. His description of pleurisy, for example, leaves no doubt that such an entity exists. His disease history on pleurisy begins, as do all his disease histories, with a discussion of the conditions that favor the onset of the illness: "This disease then which scarce is more common invades at any time of the yeare but espetialiy at that season which is between spring and summer [and] . . . it assaults for the most part persons of a sanguin and flourishing temperament." He then discusses initial symptoms that, framed in the subjective feelings of the patient, draw us into the sufferer's world: It usually begins with a rigor and horror which is succeeded with a heate inquietude and thirst and other common symptoms attending fevers. After some few howers, though sometimes after a longer space, the patient is taken with a violent pain and stitch shooting in one of his sides about the ribs which shoots up sometimes towards his shoulder and sometimes out towards the back boan or contrary wise towards the fore part of his breast. He is often provoked to cough which proves very painful to him from the straining thereby of the inflamed parts in soe much that he catches his breath and endeavours to suppresse the cough upon every first motion of the same. He spits up after coughing a matter which in the beginning of the disease is very little in quantity, thin and mixed with streaks of bloud, but in the progress thereof is for the most part plentiful thick and better concocted but mixed allso with bloud. Sometimes when the disease is very violent and bloud hath not been taken the patient is not able to cough at all but takeing his breath with great diffi-
culty he is as it were almost strangled, by the greatness of the inflammation which without intolerable pain allows not soe free an expansion of his breast as is requisite to sufficient breathing. The feaver all this while is concurreing and receaves increase also from the symptoms which its self produced but the same feaver togeather with the accidents of a cough, spitting of bloud, pain, etc. proportionably lessen as the matter of the pleurisy proceeds to a full and free expectoration. Should the disease not take this favorable turn, Sydenham discloses the more grim possibility: "But the pleuriticall matter doth not always in the progress of the disease receive this concoction fit for expectoration for it often happens that the matter which is brought up remains still little in quantity and thin as in the beginning, and the feaver consequently with all the other symptoms still hold up in their greatest vigor till the patient dyes." The disease history concludes with a statement of therapeutic outlook: "This disease in it owne nature is more dangerous than most. But if duely managed admits of cure, and with as much certainty as is suitable to the undertaking of humane endeavours in saving of mens lives, and as much as most other diseases are capable o f (3). The characteristic, or pathognomonic, symptoms defining a given disease were to be distinguished from symptoms unique to particular individuals. Sydenham's clinical acumen permitted him to distinguish the universal from the idiosyncratic signs of illness. The success of this method of classification has been great. It is the essence of diagnosis in modern medicine. However, the excessive emphasis placed on characteristic symptoms has been damaging to medical thinking. Since Sydenham's time, physicians have disregarded too often idiosyncratic symptoms that cloud the classification process. Such a focus leads to a relative obscuring or ignoring of those elements of illness that are novel expressions of the patient's self, and to a homogenizing process that can cause physicians to downplay the patient's individuality and emphasize instead the patient's connections with populations. The Clinicopathologic Correlation The concept of diseases as real entities that, like plants, have distinguishing features was pursued through the use of cases in another line of medical investigation—the autopsy. Dissecting the body, even for the worthwhile purpose of research, generally has been opposed on religious and cultural grounds. Cutting into the body of one who has recently died strikes powerful chords both psychologically and spiritually, generating an instinctive opposition to the process. However, during the Renaissance, amid a climate of renewed interest in learning generally, both artist and anatomist endeavored to study the human body—one depicting it in motion during life, the other dissecting it at rest in death. Stimulated by the 1543 treatise De humani corporis fabrica by Andreas Vesalius, which demonstrated normal human anatomy in extraordinary scientific and pictorial detail, physicians produced books on the body's pathologic transformations by disease. This research culminated 2 centuries later in
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G. B. Morgagni's 1761 treatise The Seats and Causes of Diseases Investigated by Anatomy (4). Morgagni's basic approach was to describe clinical case records that were carefully chosen from his own work and that of other physicians. After detailing the symptomatic course of a patient's illness, Morgagni recounted the findings at autopsy, those pathologic changes that had been produced by the disease in the tissues of the patient's body. He then compared the two sets of data and drew conclusions about the relation between the structural defects found after death and the symptoms experienced in life. He thus created the basic form of the clinicopathologic correlation. Here is a typical case report, which begins with the clinical history: A man of forty years of age, of a temperament partly sanguineous, and partly bilious, who had, sometimes, been affected with a slight hernia in the groins, was seiz'd with an iliac passion, after eating artichoaks. A slight tumour appear'd in the groins: yet the patient denied his having any pain there; though he confess'd he had much pain in his belly, which was very much harden'd from the retention of the faeces. All remedies being without effect, he sank under the violence of the vomitings, on the seventh day of the disease. Findings at dissection are then given: The belly being open'd, the intestines appear'd to be turgid with air, and were livid and black, in that part where, not very far from the caecum, they were doubled, and with the annex'd portion of the mesentery, which seem'd to be fleshy, as it were, descended into a hernial sacculus, which was four inches long, and had a very narrow orifice, so that they could not return back through it, into the belly, after they were distended by the matter, that had fallen down into them. This sacculus was in the right groin, and form'd out of the peritonaeum. He then reports on the anatomy of the left groin for a comparative view: Groin anatomy is found to be normal, and examination of the organs of the thorax show no significant conditions. The final part of his analysis links clinical and autopsy evidence: There was an evident cause of this pain, that is, according to the common phrase, an incarcerated hernia. . . . You readily conceive, that where this disorder arises, as it for the most part does, when an intestine is intercepted, and compress'd, that then the upper intestines are of course distended, by the matter, which is heap'd up above the interception, and that from this distention another cause of pain arises, which is also increas'd by the very corruption, of the matter collected, which corruption, is the consequence of stagnation. But how shall we suppose it to have happen'd, that in the history I have given you, the patient should deny the existence of any pain, in that part where the disorder was the greatest? He discusses possible anatomic reasons for this fact and wonders if the history, apparently taken by a physician other than himself, "was not very accurately committed to paper." This kind of case analysis produced several important changes in the way physicians viewed disease. Morgagni's anatomic orientation shifted medical thinking away from a concept of illness as a disruption of humoral 904
equilibrium (a view of illness as a system-wide event) to a concept of illness as a structural disruption in a specific anatomic portion of the body (a view of illness as a localized event). The title of Morgagni's treatise (4) proclaims this idea: Each disease had a " s e a t " in the body. The objective of the autopsy was to locate that seat and thus explain the origin of the patient's clinical symptoms. This perspective created what has since become the fundamental question of clinicians: Where is the disease? The anatomic perspective shifts the attention of physicians to portions of the body. Illness, in an anatomic view, takes up residence in a part of the body and does not represent, as in the humoral view, a state of change affecting the whole body. The concept of localized disease reinforced Sydenham's view of disease as a classifiable entity. He made diseases tangible by comparing them to biologic objects such as plants, insisting that diseases could be discovered and defined by characteristic symptoms just as plants could be distinguished through features such as color and shape. Morgagni linked this symptom-drawn portrait of illness to a specific part of the body whose disrupted fabric could be seen and touched. He thus advanced the notion of disease as a concrete entity that Sydenham had articulated, but he took the concept a step further by situating diseases in places in the body. The anatomic concept of disease provided clinicians with a theoretical justification for initiating searches in their patients for clues to the location of the pathologic changes and later justified the pursuit of a specialized approach to medical care. The idea of localized, sitespecific disease makes it logical to divide the body geographically, assigning the exploration of each part to a specialist who has a detailed knowledge of the particular area. The anatomic approach to medicine also stimulated an interest in developing technologies to assist in this search into places, as events occurring little more than 50 years after Morgagni's work demonstrated. Case Records and the Entry of Technology into Diagnosis The case histories and clinical records of the nineteenth century are distinguished from those preceding them by a focus on disease signs discovered using technologic aids. The first technology receiving wide use in diagnosis was invented in 1816 by the French physician Rene Laennec. The invention represented a response to the limitations of the subjective reports of patients, which, at the time, were the principal source of diagnostic evidence for doctors, as well as a means to surmount the traditional convention that limited direct physical examination of the patient as conduct unbecoming to the gentleman doctor. Laennec had found himself baffled by the nature of a young woman's heart ailment; a student of the Hippocratic literature, he was aware of a technique discussed there of applying the ear to the patient's chest to gain from the sounds heard insights into illness. One of Laennec's colleagues, Gaspard Bayle, occasionally used this technique, but Laennec found it displeasing personally. He was conscious too that it embarrassed the patients on whom it was used. Recalling a fact of physics—that solid bodies augment sound—Laennec thought of a way to apply the
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technique without making direct contact with the patient's body. He seized a sheaf of paper lying on a table by the patient's bed, rolled it tightly into a tube, and placed one end on the patient's chest and the other to his ear. The sounds of the heart rose clearly to him through the tube. He immediately recognized the possibilities of using this tube to seek, in the sounds produced by chest organs, indices of health and illness. The success of this technique, called auscultation, and the instrument he invented for it, which he named the stethoscope, are documented in a book published in 1819 after 3 years of intensive research, De Vauscultation mediate. The research adopted and helped promote Morgagni's method of comparing and verifying clinical signs with autopsy findings. The power of the technique for diagnosis also gave legitimacy to the doctor's use of technology to examine patients, an activity that had been thwarted by a tradition that associated tools with tradesmen and thus found their use inappropriate to the professional dignity of physicians. The book established too a new view of illness, as the clinician observed and depicted it in records. Older clinical descriptions had been based on patients' recollections of possible antecedent causes and on subjective experiences they felt on the way to becoming ill. If, for example, one examines Sydenham's clinical description of pleurisy (see above), one finds it a construction dominated by the patient's subjective sensations and experiences. It is a tale of "rigor," ''inquietude," "thirst," "violent pain," and of feeling "strangled" (3). With Laennec the nature of the case history changes; the doctor's observations replace the patient's as the focus. Laennec's case histories document the beginning of a new era of physical diagnosis, one that prevailed throughout the nineteenth century. The case records of this era show the patient's persona receding from view, replaced by a detailed description of the physical indices of anatomic change. One of Laennec's case histories, which is accompanied by the autopsy report, now a growing component of medical records, shows the new emphasis. The first sentence is a thumbnail sketch of the patient and his view of the illness: "A man, aged 65, came into hospital on the 29th of November, affected with slight pulmonary symptoms, chiefly marked by dyspnoea, to which he had been long subject, and which he considered as asthma." This brief sketch yields quickly to the physician's immersion in the anatomy of illness as transmitted through sound: Percussion afforded no result, owing to the excessive fatness of the individual; only the chest appeared to sound somewhat less below the right clavicle. Respiration was inaudible over the whole of the right side, but was very sonorous on the left. From these results I considered this person as affected with a latent peripneumony of the right lung. Five days after this, there was observed slight oedema of the right side of the chest; and on applying the stethoscope to the back, respiration was somewhat perceptible along the edge of the spine on the right side, though less so than on the left. There was very little cough, and scarcely any expectoration. These symptoms indicating pleurisy rather than peripneumony, necessarily modified our diagnostics. After a few days the oppression became less, and we began to hear the sound of respiration, in a slight degree,
below the right clavicle, and haegophonism was perceptible in the same spot for a few days. On the eleventh the chest sounded still better in this point, and respiration became distinct as in the opposite side, but was not perceptible lower than the third rib. It was, also, sufficiently distinct between the spine and scapula. At this time the patient expectorated some opaque, yellow, puriform sputa. The symptoms continued much the same until the middle of February, when he died, apparently from an attack of peritonitis. A meticulous autopsy focusing on the chest was done 24 hours after the patient's death. Typically, in such autopsies, anatomic findings not detected clinically received special attention. In this case, an enlarged heart had been missed: "This well-marked case of hypertrophia had not been suspected, although the heart had been examined several times by the stethoscope, owing to the existence of the disease in the lungs, which masked the symptoms" (5). As the nineteenth century progressed, physicians developed many simple tools that, like the stethoscope, extended their senses (for example, the ophthalmoscope and the laryngoscope). Clinicians became bedside detectives, searching for physical clues. Indeed, this meticulous evaluation of evidence gave rise to the quintessential detective of modern literature, Sherlock Holmes. Invented in the late nineteenth century by Dr. Arthur Conan Doyle, a physician educated in the new method of physical diagnosis, Holmes was in part modeled on one of Doyle's teachers at the Edinburgh Infirmary, Dr. Joseph Bell. Dr. Bell's medical skills in observation and deduction provided a creative stimulus that eventually led Conan Doyle, as he put it, "to forsake medicine for story writing" (6). Case Records and the Appraisal of Therapy After the innovations of Morgagni and Laennec, the clinical case and autopsy records became central objects of medical research on the cause and diagnosis of disease. The study of case records also became important for the evaluation of therapy in the nineteenth century. The ground-breaking work in this area was written by the French physician Pierre Louis in 1835, in which he disproved the wide effectiveness claimed for the principal therapy not only of his day, but of centuries before—bloodletting. In the opening paragraph of Researches on the Effect of Bloodletting, Louis confesses his apprehension about publishing conclusions that contradicted current opinion: Only after repeating his investigation could he bring himself to reveal his findings, which were based on a form of analysis that was as far-reaching as the study's conclusion. To determine the effects of bloodletting, Louis analyzed clinical cases of patients suffering from pneumonia and erysepilas using a numerical method. He found that the amount, timing, or frequency of the bleeding had no influence on the outcome and that any apparent effect could be attributed to either a wrong diagnosis or to the use of bloodletting in a patient whose disease had nearly run its course. The aspects of this method critics found most objectionable were thinking it possible to bring together sim-
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A middle-aged m a n w a s seen w r i t h i n g i n intense p a i n referred to t h e epigastrium. Vomiting of greenish fluid took place; t h e r e were loose discharges from t h e bowels, small i n amount. This state of t h i n g s lasted, w i t h only short remissions, for two days, until a small dose of morphia, which, for special reasons, h a d been hitherto withheld though asked for, w a s administered, after w h i c h there w a s complete relief for m a n y days. The pupils were dilated, the pulse regular and of normal character. Nothing special h a d been eaten or drunk to cause irritation of the stomach. The abdominal walls were neither distended n o r retracted, no intra-abdominal tumor w a s to be detected, n o r w a s t h e r e a n y excessive t e n d e r n e s s on pressure. It w a s afterwards learned t h a t h e h a d h a d several such attacks, t h a t for m a n y m o n t h s or years his legs h a d been weak, t h a t h e h a d neuralgia and numbness in them, t h a t h e stumbled in walking and staggered with h i s eyes shut.
Figure 1. A brief case given out by an instructor to Walter Cannon and other Harvard students for discussion with Cannon's comments on its educational significance. Cannon, WD. The case system in medicine. Boston Medical and Surgical Journal. 1900;142:563-4.
Here we have a real and vivid description of a gastric crisis in tabes, made so striking that it leaves a deep and permanent impression in the memory. This case also illustrated another of the unexpected features of the case method, that of showing to the students themselves and also to their instructor what they do not know and wherein their knowledge is inaccurate. At the end of this record of a gastric crisis the question was asked, "What further examination would you make?" This one question alone showed about one-half the students present that they were entirely wrong in their memory of the Argyll-Robertson pupil, and the question further showed that a large number of the graduating class believed that the knee-jerk was ordinarily increased in tabes. These are merely instances of the state of affairs among the students which the method is bringing to light. They are going through their last year in the school ignorant of their ignorance and complacent in their false knowledge until meeting the actual conditions of real cases shows them their deficiencies.
ilar cases for comparison, and seeking to erase differences in the patients of the study population in order to analyze them. Louis insisted that the numerical method, as he used it, was not intended to and did not erase differences; rather, "it supposed them." If facts not strictly similar were combined, these differences, he wrote, "will be distributed through the different groups or classes of facts and will be equalized; so that a comparison can be instituted between several groups without altering the result." He urged doctors to "bestow upon observation the care and time which it demands; let the facts be vigorously analyzed in order to [reach] a just appreciation of them; and it is impossible to attain this without classifying and counting them; and then therapeutics will advance not less steadily than other branches of science" (7). Louis sought to bring together the diverse experiences represented in clinical case records of different patients treated by different doctors. He declared emphatically, "If then there is a means of embodying the experience of ages, it is the numerical method" (7). Case Records and the Education of Doctors Although clinical case records played a critical role in advancing the practice and science of medicine, only in the twentieth century did they become fundamental tools of medical education. A student at Harvard Medical School, Walter Cannon, was instrumental in effecting changes in teaching methods through the use of cases. Cannon had become convinced that the lecture as a means of transmitting medical knowledge had significant limitations. Its form made learning a passive experience that did not teach students how to balance 906
and weigh evidence, and its content was generally devoid of experiences of patients and doctors with illness that students would encounter after graduation. The primacy of the lecture had created a situation in which the students' "chief practice is taking lecture notes" (8). Bedside teaching seemed to provide the most productive alternative, but this method also had limitations: It was often impossible for beginning or even advanced students to follow over time a patient's course of illness as it unfolded in the hospital and after discharge. Cannon discovered in the case histories abstracted from the clinical records of Harvard teaching hospitals and instructors an answer to the problems that both the lecture and bedside teaching presented to medical learning. The cases allowed students to be active analysts, rather than static listeners, engaging them in brisk discussion of the logic used and actions taken in treating a particular patient. They also permitted the student to see the full range of developments in the evolution of a patient's illness, from its causes and diagnosis, to establishing and implementing the therapeutic plan, and finally to testing its value by measures of outcome such as the patient's activities after discharge and autopsy findings. The students would be examined for these analytic abilities by having to establish therapy and predict results in cases presented to them (Figure 1). The idea for using cases in this systematic manner did not originate with Cannon. Rather, as he acknowledged, it began with Professor C. C. Langdell, who had initiated case teaching 30 years earlier at Harvard Law School. As in law, the method became a success in medicine, and early supporters of the concept included
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leading educators such as Harvard president Charles Eliot. A decade later, a second teaching innovation based on the case history was introduced, this time in a hospital and for the instruction of practitioners. Richard C. Cabot, a physician at the Massachusetts General Hospital, and James Homer Wright, a pathologist there, inaugurated in 1910 a series of weekly conferences. In the conferences, a physician commented on the clinical logic detailed in the hospital record of a patient whom the doctor had not treated, and presented views on diagnostic conclusions appropriately drawn from the evidence the record contained. The clinician was followed by a pathologist, who disclosed autopsy findings that affirmed or denied the clinician's analysis. Thus, the clinicopathologic correlation, suggested nearly a century and a half before by Morgagni as the cornerstone of medical thinking, was introduced as a mode of hospital education and named the clinical-pathological conference. The idea caught the imagination of practitioners. At one level, they were enthralled by the event as a contest—the clinician's skill versus the pathologist's learning. This worried Cabot. He was drawn to emphasize that the chief end of the exercise was not seeing if the clinician got the diagnosis right, but learning from the reasoning used how best to judge evidence, balance probabilities, and compare clinical and autopsy findings. A medical audience for this exercise grew up outside of the hospital, when Massachusetts General Hospital began in 1915 to publish the exercises through subscription. "To a great many of us," wrote a doctor in 1918, "these cases are the only postgraduate work we have at the present time" (9). Alan Gregg, Director of Medical Sciences for the Rockefeller Foundation, reported that
the conference drew "wonder and admiration" from international visitors "who see in it a candor and fearlessness altogether to the credit of American medicine" (10). In 1923, these clinical-pathologic conferences, or Cabot Case Records as they sometimes were called, became the subject of a regular column in the Boston Medical and Surgical Journal, renamed The New England Journal of Medicine in 1928, where it remains a prominent feature to this day. Requests for Reprints: Stanley J. Reiser, MD, PhD, University of Texas Health Science Center at Houston, P.O. Box 20708, Houston, TX 77225. Current Author Address: Dr. Reiser: University of Texas Health Science Center at Houston, P.O. Box 20708, Houston, TX 77225.
Annals of Internal Medicine. 1990;114:902-907. References 1. Epidemics III. In: Jones WH, ed. Hippocrates. Volume 1. Cambridge, Massachusetts: Harvard University Press; 1923:279. 2. The art. In: Jones WH, ed. Hippocrates. Volume 2. Cambridge, Massachusetts: Harvard University Press; 1923:193, 203. 3. Sydenham T. In: Dewhurst K, ed. Dr. Thomas Sydenham (16241689): His Life and Original Writings. Berkeley, California: University of California Press; 1966:60, 127-8. 4. Morgagni GB. The Seats and Causes of Diseases Investigated by Anatomy. Volume 2. New York: Hafner Press; 1960:127-8. 5. Laennec RT. A Treatise on the Diseases of the Chest. John Forbes, trans. New York: Hafner Press; 1962:398-400. 6. Rodin AE, Key JE. Medical Casebook of Doctor Arthur Conan Doyle: From Practitioner to Sherlock Holmes and Beyond. Malabar, Florida: Robert S. Krieger; 1984:199. 7. Louis PC. Researches on the Effects of Bloodletting. Boston: Hilliard, Gray and Company; 1836:64-5. 8. Cannon WH. The case method of teaching systematic medicine. Boston Medical and Surgical Journal. 1900; 142:32. 9. Painter FM. Extending the influence of a hospital. The Modern Hospital. 1918;2:356. 10. Washburn FA. The Massachusetts General Hospital: Its Development. 1900-1935. Boston: Houghton, Mifflin; 1939:117.
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The Clinical Record in Medicine Part 1: Learning from Cases* Stanley J. Reiser, MD, PhD
1 he clinical case record freezes in time that episode in life called illness. It is a story in which patient and family are the main characters, with the doctor serving a dual purpose as both biographer and part of the plot. The content of this biography varies greatly, reflecting its many purposes: to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions. In this essay, I discuss how clinical cases have shaped and reflected learning and action in medicine and how the document in which these cases are inscribed—the clinical record—has influenced medicine. Cases and Records in Hippocratic Medicine Like other important developments in Western medicine, the clinical record was advanced significantly in Greece in the fifth century B.C.E., when medical practice was dominated by Hippocrates and his disciples. Case records in the Hippocratic literature have two basic functions: to demonstrate the natural causes of illness and to portray the clinical course of illness through accurate observations of the patient's symptoms. The pursuit of this twofold task required doctors to be open and honest regarding the outcomes of the treatment they administered. The integrity of the record is evident in the Hippocratic cases, for in many instances the patient dies. The format of the Hippocratic case record is chronologic. First, preceding causes and presenting symptoms are documented, as in the case of Apollonius in Abdera (1). Apollonius "was ailing for a long time without being confined to bed. He had a swollen abdomen, and a continual pain in the region of the liver had been present for a long time; moreover, he became during this period jaundiced and flatulent; his complexion was whitish." Next, we learn of the actions and symptoms that bring the patient to seek care. After dining one day and drinking to excess, Apollonius "at first grew rather hot [and] he took to his bed." "Having drunk copiously of milk, boiled and raw, both goat's and sheep's, and adopting a thoroughly bad regimen, he suffered much therefrom." Reports on the progress of the illness follow. These are not written daily, but at times when important changes in symptoms occur, as in the following: A version of this essay was presented at a symposium, "The Medical Journal: Past, Present, and Future," held in honor of Edward J. Huth, Editor of Annals of Internal Medicine, on 14 September 1989. Dr. Huth retired as Editor on 30 June 1990. The papers from the symposium will be published in a Festschrift in his honor. * The second part of the article focuses on twentieth century improvements in the content and purpose of the case record. It will appear in the 1 June 1991 issue.
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There were exacerbations of the fever; the bowels passed practically nothing of the food taken; the urine was thin and scanty. No sleep. Grievous distension; much thirst; coma; painful swelling of the right hypochondrium; extremities all round rather cold; slight delirious mutterings; forgetfulness of everything he said; he was not himself. About the fourteenth day from his taking to bed, after a rigor, he grew hot; wildly delirious; shouting, distress, much rambling, followed by calm; the coma came on at this time. . . . About the twenty-fourth day comfortable; in other respects the same, but he had lucid intervals. He remembered nothing since he took to bed. But he quickly was again delirious, and all symptoms took a sharp turn for the worse. About the thirtieth day acute fever; copious, thin stools; wandering; cold extremities; speechlessness. The Hippocratic cases generally conclude by disclosing the result, which is often, as in the case of Apollonius of Abdera, given starkly: 'Thirty-fourth day. Death." The chronologic ordering of events in these case records reveals the Greek concern with therapeutic timing. To the Greeks, deciding when to use an intervention was as important as deciding what intervention to use, for a particular remedy was thought to have a different effect depending on the stage of the illness in which it was given. Chronologic portrayal also focused attention on the symptoms most predictive of outcome. The Hippocratic physician used this prognostic power to decide which cases to accept or decline. This action had its origin in a fundamental tenet of Greek medicine of this period, namely, that futile therapy should not be used. To pursue a treatment that could not succeed not only harmed the patient but diminished the standing of the practitioner and the reputation of medicine itself. This viewpoint, which has an uncanny bearing on modern medical practice where much anguish often attends decisions to withdraw or withhold therapy, is stated eloquently in the Hippocratic essay "The Art" (2): I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless. . . . For if a man demand from an art a power over what does not belong to the art, or from nature a power over what does not belong to nature, his ignorance is more allied to madness than to lack of knowledge. For in cases where we have the mastery through the means afforded by a natural constitution or by an art, there we may be craftsmen, but nowhere else. Prognostic learning and insightful therapeutic timing were perhaps the most important skills a Hippocratic physician could have. The case history, by its revealing chronology of illness, furthered their attainment.
© 1991 American College of Physicians
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Role of Clinical Cases in Creating Disease Categories The use of case records to uncover fundamental knowledge about illness was greatly furthered in the seventeenth century through the work of Thomas Sydenham, called by admirers the ''English Hippocrates." In his time, symptoms were generally not classified into entities called diseases (although epidemic disorders were named). Rather, physicians of this era attributed sickness to a single causal mechanism that had been recognized at least since Hippocratic times—disruption of the equilibrium of the body's four main building blocks or humors (blood, phlegm, black bile, yellow bile). The basic illness therefore was humoral disruption. When this occurred, the result of initiating pathologic factors such as climatic changes or excessive consumption of food or drink, different symptoms expressed the new proportions of the relation among the humors. Sydenham began to recognize similarities in the patterns of symptoms of the patients he treated. Living in an age when the classification of plants and animals received much attention, Sydenham showed the influence of this intellectual climate when he hypothesized that illnesses might have tangible forms that could be classified by the unique conjunction of their characteristic symptoms, just as plants could be classified by their characteristic features: "It is necessary that all diseases be reduced to definite and certain species and that, with the same care which we see exhibited by botanists" (3). Sydenham's great contribution was to synthesize from clinical records the case histories of individual patients into a disease history. His description of pleurisy, for example, leaves no doubt that such an entity exists. His disease history on pleurisy begins, as do all his disease histories, with a discussion of the conditions that favor the onset of the illness: "This disease then which scarce is more common invades at any time of the yeare but espetialiy at that season which is between spring and summer [and] . . . it assaults for the most part persons of a sanguin and flourishing temperament." He then discusses initial symptoms that, framed in the subjective feelings of the patient, draw us into the sufferer's world: It usually begins with a rigor and horror which is succeeded with a heate inquietude and thirst and other common symptoms attending fevers. After some few howers, though sometimes after a longer space, the patient is taken with a violent pain and stitch shooting in one of his sides about the ribs which shoots up sometimes towards his shoulder and sometimes out towards the back boan or contrary wise towards the fore part of his breast. He is often provoked to cough which proves very painful to him from the straining thereby of the inflamed parts in soe much that he catches his breath and endeavours to suppresse the cough upon every first motion of the same. He spits up after coughing a matter which in the beginning of the disease is very little in quantity, thin and mixed with streaks of bloud, but in the progress thereof is for the most part plentiful thick and better concocted but mixed allso with bloud. Sometimes when the disease is very violent and bloud hath not been taken the patient is not able to cough at all but takeing his breath with great diffi-
culty he is as it were almost strangled, by the greatness of the inflammation which without intolerable pain allows not soe free an expansion of his breast as is requisite to sufficient breathing. The feaver all this while is concurreing and receaves increase also from the symptoms which its self produced but the same feaver togeather with the accidents of a cough, spitting of bloud, pain, etc. proportionably lessen as the matter of the pleurisy proceeds to a full and free expectoration. Should the disease not take this favorable turn, Sydenham discloses the more grim possibility: "But the pleuriticall matter doth not always in the progress of the disease receive this concoction fit for expectoration for it often happens that the matter which is brought up remains still little in quantity and thin as in the beginning, and the feaver consequently with all the other symptoms still hold up in their greatest vigor till the patient dyes." The disease history concludes with a statement of therapeutic outlook: "This disease in it owne nature is more dangerous than most. But if duely managed admits of cure, and with as much certainty as is suitable to the undertaking of humane endeavours in saving of mens lives, and as much as most other diseases are capable o f (3). The characteristic, or pathognomonic, symptoms defining a given disease were to be distinguished from symptoms unique to particular individuals. Sydenham's clinical acumen permitted him to distinguish the universal from the idiosyncratic signs of illness. The success of this method of classification has been great. It is the essence of diagnosis in modern medicine. However, the excessive emphasis placed on characteristic symptoms has been damaging to medical thinking. Since Sydenham's time, physicians have disregarded too often idiosyncratic symptoms that cloud the classification process. Such a focus leads to a relative obscuring or ignoring of those elements of illness that are novel expressions of the patient's self, and to a homogenizing process that can cause physicians to downplay the patient's individuality and emphasize instead the patient's connections with populations. The Clinicopathologic Correlation The concept of diseases as real entities that, like plants, have distinguishing features was pursued through the use of cases in another line of medical investigation—the autopsy. Dissecting the body, even for the worthwhile purpose of research, generally has been opposed on religious and cultural grounds. Cutting into the body of one who has recently died strikes powerful chords both psychologically and spiritually, generating an instinctive opposition to the process. However, during the Renaissance, amid a climate of renewed interest in learning generally, both artist and anatomist endeavored to study the human body—one depicting it in motion during life, the other dissecting it at rest in death. Stimulated by the 1543 treatise De humani corporis fabrica by Andreas Vesalius, which demonstrated normal human anatomy in extraordinary scientific and pictorial detail, physicians produced books on the body's pathologic transformations by disease. This research culminated 2 centuries later in
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G. B. Morgagni's 1761 treatise The Seats and Causes of Diseases Investigated by Anatomy (4). Morgagni's basic approach was to describe clinical case records that were carefully chosen from his own work and that of other physicians. After detailing the symptomatic course of a patient's illness, Morgagni recounted the findings at autopsy, those pathologic changes that had been produced by the disease in the tissues of the patient's body. He then compared the two sets of data and drew conclusions about the relation between the structural defects found after death and the symptoms experienced in life. He thus created the basic form of the clinicopathologic correlation. Here is a typical case report, which begins with the clinical history: A man of forty years of age, of a temperament partly sanguineous, and partly bilious, who had, sometimes, been affected with a slight hernia in the groins, was seiz'd with an iliac passion, after eating artichoaks. A slight tumour appear'd in the groins: yet the patient denied his having any pain there; though he confess'd he had much pain in his belly, which was very much harden'd from the retention of the faeces. All remedies being without effect, he sank under the violence of the vomitings, on the seventh day of the disease. Findings at dissection are then given: The belly being open'd, the intestines appear'd to be turgid with air, and were livid and black, in that part where, not very far from the caecum, they were doubled, and with the annex'd portion of the mesentery, which seem'd to be fleshy, as it were, descended into a hernial sacculus, which was four inches long, and had a very narrow orifice, so that they could not return back through it, into the belly, after they were distended by the matter, that had fallen down into them. This sacculus was in the right groin, and form'd out of the peritonaeum. He then reports on the anatomy of the left groin for a comparative view: Groin anatomy is found to be normal, and examination of the organs of the thorax show no significant conditions. The final part of his analysis links clinical and autopsy evidence: There was an evident cause of this pain, that is, according to the common phrase, an incarcerated hernia. . . . You readily conceive, that where this disorder arises, as it for the most part does, when an intestine is intercepted, and compress'd, that then the upper intestines are of course distended, by the matter, which is heap'd up above the interception, and that from this distention another cause of pain arises, which is also increas'd by the very corruption, of the matter collected, which corruption, is the consequence of stagnation. But how shall we suppose it to have happen'd, that in the history I have given you, the patient should deny the existence of any pain, in that part where the disorder was the greatest? He discusses possible anatomic reasons for this fact and wonders if the history, apparently taken by a physician other than himself, "was not very accurately committed to paper." This kind of case analysis produced several important changes in the way physicians viewed disease. Morgagni's anatomic orientation shifted medical thinking away from a concept of illness as a disruption of humoral 904
equilibrium (a view of illness as a system-wide event) to a concept of illness as a structural disruption in a specific anatomic portion of the body (a view of illness as a localized event). The title of Morgagni's treatise (4) proclaims this idea: Each disease had a " s e a t " in the body. The objective of the autopsy was to locate that seat and thus explain the origin of the patient's clinical symptoms. This perspective created what has since become the fundamental question of clinicians: Where is the disease? The anatomic perspective shifts the attention of physicians to portions of the body. Illness, in an anatomic view, takes up residence in a part of the body and does not represent, as in the humoral view, a state of change affecting the whole body. The concept of localized disease reinforced Sydenham's view of disease as a classifiable entity. He made diseases tangible by comparing them to biologic objects such as plants, insisting that diseases could be discovered and defined by characteristic symptoms just as plants could be distinguished through features such as color and shape. Morgagni linked this symptom-drawn portrait of illness to a specific part of the body whose disrupted fabric could be seen and touched. He thus advanced the notion of disease as a concrete entity that Sydenham had articulated, but he took the concept a step further by situating diseases in places in the body. The anatomic concept of disease provided clinicians with a theoretical justification for initiating searches in their patients for clues to the location of the pathologic changes and later justified the pursuit of a specialized approach to medical care. The idea of localized, sitespecific disease makes it logical to divide the body geographically, assigning the exploration of each part to a specialist who has a detailed knowledge of the particular area. The anatomic approach to medicine also stimulated an interest in developing technologies to assist in this search into places, as events occurring little more than 50 years after Morgagni's work demonstrated. Case Records and the Entry of Technology into Diagnosis The case histories and clinical records of the nineteenth century are distinguished from those preceding them by a focus on disease signs discovered using technologic aids. The first technology receiving wide use in diagnosis was invented in 1816 by the French physician Rene Laennec. The invention represented a response to the limitations of the subjective reports of patients, which, at the time, were the principal source of diagnostic evidence for doctors, as well as a means to surmount the traditional convention that limited direct physical examination of the patient as conduct unbecoming to the gentleman doctor. Laennec had found himself baffled by the nature of a young woman's heart ailment; a student of the Hippocratic literature, he was aware of a technique discussed there of applying the ear to the patient's chest to gain from the sounds heard insights into illness. One of Laennec's colleagues, Gaspard Bayle, occasionally used this technique, but Laennec found it displeasing personally. He was conscious too that it embarrassed the patients on whom it was used. Recalling a fact of physics—that solid bodies augment sound—Laennec thought of a way to apply the
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technique without making direct contact with the patient's body. He seized a sheaf of paper lying on a table by the patient's bed, rolled it tightly into a tube, and placed one end on the patient's chest and the other to his ear. The sounds of the heart rose clearly to him through the tube. He immediately recognized the possibilities of using this tube to seek, in the sounds produced by chest organs, indices of health and illness. The success of this technique, called auscultation, and the instrument he invented for it, which he named the stethoscope, are documented in a book published in 1819 after 3 years of intensive research, De Vauscultation mediate. The research adopted and helped promote Morgagni's method of comparing and verifying clinical signs with autopsy findings. The power of the technique for diagnosis also gave legitimacy to the doctor's use of technology to examine patients, an activity that had been thwarted by a tradition that associated tools with tradesmen and thus found their use inappropriate to the professional dignity of physicians. The book established too a new view of illness, as the clinician observed and depicted it in records. Older clinical descriptions had been based on patients' recollections of possible antecedent causes and on subjective experiences they felt on the way to becoming ill. If, for example, one examines Sydenham's clinical description of pleurisy (see above), one finds it a construction dominated by the patient's subjective sensations and experiences. It is a tale of "rigor," ''inquietude," "thirst," "violent pain," and of feeling "strangled" (3). With Laennec the nature of the case history changes; the doctor's observations replace the patient's as the focus. Laennec's case histories document the beginning of a new era of physical diagnosis, one that prevailed throughout the nineteenth century. The case records of this era show the patient's persona receding from view, replaced by a detailed description of the physical indices of anatomic change. One of Laennec's case histories, which is accompanied by the autopsy report, now a growing component of medical records, shows the new emphasis. The first sentence is a thumbnail sketch of the patient and his view of the illness: "A man, aged 65, came into hospital on the 29th of November, affected with slight pulmonary symptoms, chiefly marked by dyspnoea, to which he had been long subject, and which he considered as asthma." This brief sketch yields quickly to the physician's immersion in the anatomy of illness as transmitted through sound: Percussion afforded no result, owing to the excessive fatness of the individual; only the chest appeared to sound somewhat less below the right clavicle. Respiration was inaudible over the whole of the right side, but was very sonorous on the left. From these results I considered this person as affected with a latent peripneumony of the right lung. Five days after this, there was observed slight oedema of the right side of the chest; and on applying the stethoscope to the back, respiration was somewhat perceptible along the edge of the spine on the right side, though less so than on the left. There was very little cough, and scarcely any expectoration. These symptoms indicating pleurisy rather than peripneumony, necessarily modified our diagnostics. After a few days the oppression became less, and we began to hear the sound of respiration, in a slight degree,
below the right clavicle, and haegophonism was perceptible in the same spot for a few days. On the eleventh the chest sounded still better in this point, and respiration became distinct as in the opposite side, but was not perceptible lower than the third rib. It was, also, sufficiently distinct between the spine and scapula. At this time the patient expectorated some opaque, yellow, puriform sputa. The symptoms continued much the same until the middle of February, when he died, apparently from an attack of peritonitis. A meticulous autopsy focusing on the chest was done 24 hours after the patient's death. Typically, in such autopsies, anatomic findings not detected clinically received special attention. In this case, an enlarged heart had been missed: "This well-marked case of hypertrophia had not been suspected, although the heart had been examined several times by the stethoscope, owing to the existence of the disease in the lungs, which masked the symptoms" (5). As the nineteenth century progressed, physicians developed many simple tools that, like the stethoscope, extended their senses (for example, the ophthalmoscope and the laryngoscope). Clinicians became bedside detectives, searching for physical clues. Indeed, this meticulous evaluation of evidence gave rise to the quintessential detective of modern literature, Sherlock Holmes. Invented in the late nineteenth century by Dr. Arthur Conan Doyle, a physician educated in the new method of physical diagnosis, Holmes was in part modeled on one of Doyle's teachers at the Edinburgh Infirmary, Dr. Joseph Bell. Dr. Bell's medical skills in observation and deduction provided a creative stimulus that eventually led Conan Doyle, as he put it, "to forsake medicine for story writing" (6). Case Records and the Appraisal of Therapy After the innovations of Morgagni and Laennec, the clinical case and autopsy records became central objects of medical research on the cause and diagnosis of disease. The study of case records also became important for the evaluation of therapy in the nineteenth century. The ground-breaking work in this area was written by the French physician Pierre Louis in 1835, in which he disproved the wide effectiveness claimed for the principal therapy not only of his day, but of centuries before—bloodletting. In the opening paragraph of Researches on the Effect of Bloodletting, Louis confesses his apprehension about publishing conclusions that contradicted current opinion: Only after repeating his investigation could he bring himself to reveal his findings, which were based on a form of analysis that was as far-reaching as the study's conclusion. To determine the effects of bloodletting, Louis analyzed clinical cases of patients suffering from pneumonia and erysepilas using a numerical method. He found that the amount, timing, or frequency of the bleeding had no influence on the outcome and that any apparent effect could be attributed to either a wrong diagnosis or to the use of bloodletting in a patient whose disease had nearly run its course. The aspects of this method critics found most objectionable were thinking it possible to bring together sim-
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A middle-aged m a n w a s seen w r i t h i n g i n intense p a i n referred to t h e epigastrium. Vomiting of greenish fluid took place; t h e r e were loose discharges from t h e bowels, small i n amount. This state of t h i n g s lasted, w i t h only short remissions, for two days, until a small dose of morphia, which, for special reasons, h a d been hitherto withheld though asked for, w a s administered, after w h i c h there w a s complete relief for m a n y days. The pupils were dilated, the pulse regular and of normal character. Nothing special h a d been eaten or drunk to cause irritation of the stomach. The abdominal walls were neither distended n o r retracted, no intra-abdominal tumor w a s to be detected, n o r w a s t h e r e a n y excessive t e n d e r n e s s on pressure. It w a s afterwards learned t h a t h e h a d h a d several such attacks, t h a t for m a n y m o n t h s or years his legs h a d been weak, t h a t h e h a d neuralgia and numbness in them, t h a t h e stumbled in walking and staggered with h i s eyes shut.
Figure 1. A brief case given out by an instructor to Walter Cannon and other Harvard students for discussion with Cannon's comments on its educational significance. Cannon, WD. The case system in medicine. Boston Medical and Surgical Journal. 1900;142:563-4.
Here we have a real and vivid description of a gastric crisis in tabes, made so striking that it leaves a deep and permanent impression in the memory. This case also illustrated another of the unexpected features of the case method, that of showing to the students themselves and also to their instructor what they do not know and wherein their knowledge is inaccurate. At the end of this record of a gastric crisis the question was asked, "What further examination would you make?" This one question alone showed about one-half the students present that they were entirely wrong in their memory of the Argyll-Robertson pupil, and the question further showed that a large number of the graduating class believed that the knee-jerk was ordinarily increased in tabes. These are merely instances of the state of affairs among the students which the method is bringing to light. They are going through their last year in the school ignorant of their ignorance and complacent in their false knowledge until meeting the actual conditions of real cases shows them their deficiencies.
ilar cases for comparison, and seeking to erase differences in the patients of the study population in order to analyze them. Louis insisted that the numerical method, as he used it, was not intended to and did not erase differences; rather, "it supposed them." If facts not strictly similar were combined, these differences, he wrote, "will be distributed through the different groups or classes of facts and will be equalized; so that a comparison can be instituted between several groups without altering the result." He urged doctors to "bestow upon observation the care and time which it demands; let the facts be vigorously analyzed in order to [reach] a just appreciation of them; and it is impossible to attain this without classifying and counting them; and then therapeutics will advance not less steadily than other branches of science" (7). Louis sought to bring together the diverse experiences represented in clinical case records of different patients treated by different doctors. He declared emphatically, "If then there is a means of embodying the experience of ages, it is the numerical method" (7). Case Records and the Education of Doctors Although clinical case records played a critical role in advancing the practice and science of medicine, only in the twentieth century did they become fundamental tools of medical education. A student at Harvard Medical School, Walter Cannon, was instrumental in effecting changes in teaching methods through the use of cases. Cannon had become convinced that the lecture as a means of transmitting medical knowledge had significant limitations. Its form made learning a passive experience that did not teach students how to balance 906
and weigh evidence, and its content was generally devoid of experiences of patients and doctors with illness that students would encounter after graduation. The primacy of the lecture had created a situation in which the students' "chief practice is taking lecture notes" (8). Bedside teaching seemed to provide the most productive alternative, but this method also had limitations: It was often impossible for beginning or even advanced students to follow over time a patient's course of illness as it unfolded in the hospital and after discharge. Cannon discovered in the case histories abstracted from the clinical records of Harvard teaching hospitals and instructors an answer to the problems that both the lecture and bedside teaching presented to medical learning. The cases allowed students to be active analysts, rather than static listeners, engaging them in brisk discussion of the logic used and actions taken in treating a particular patient. They also permitted the student to see the full range of developments in the evolution of a patient's illness, from its causes and diagnosis, to establishing and implementing the therapeutic plan, and finally to testing its value by measures of outcome such as the patient's activities after discharge and autopsy findings. The students would be examined for these analytic abilities by having to establish therapy and predict results in cases presented to them (Figure 1). The idea for using cases in this systematic manner did not originate with Cannon. Rather, as he acknowledged, it began with Professor C. C. Langdell, who had initiated case teaching 30 years earlier at Harvard Law School. As in law, the method became a success in medicine, and early supporters of the concept included
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leading educators such as Harvard president Charles Eliot. A decade later, a second teaching innovation based on the case history was introduced, this time in a hospital and for the instruction of practitioners. Richard C. Cabot, a physician at the Massachusetts General Hospital, and James Homer Wright, a pathologist there, inaugurated in 1910 a series of weekly conferences. In the conferences, a physician commented on the clinical logic detailed in the hospital record of a patient whom the doctor had not treated, and presented views on diagnostic conclusions appropriately drawn from the evidence the record contained. The clinician was followed by a pathologist, who disclosed autopsy findings that affirmed or denied the clinician's analysis. Thus, the clinicopathologic correlation, suggested nearly a century and a half before by Morgagni as the cornerstone of medical thinking, was introduced as a mode of hospital education and named the clinical-pathological conference. The idea caught the imagination of practitioners. At one level, they were enthralled by the event as a contest—the clinician's skill versus the pathologist's learning. This worried Cabot. He was drawn to emphasize that the chief end of the exercise was not seeing if the clinician got the diagnosis right, but learning from the reasoning used how best to judge evidence, balance probabilities, and compare clinical and autopsy findings. A medical audience for this exercise grew up outside of the hospital, when Massachusetts General Hospital began in 1915 to publish the exercises through subscription. "To a great many of us," wrote a doctor in 1918, "these cases are the only postgraduate work we have at the present time" (9). Alan Gregg, Director of Medical Sciences for the Rockefeller Foundation, reported that
the conference drew "wonder and admiration" from international visitors "who see in it a candor and fearlessness altogether to the credit of American medicine" (10). In 1923, these clinical-pathologic conferences, or Cabot Case Records as they sometimes were called, became the subject of a regular column in the Boston Medical and Surgical Journal, renamed The New England Journal of Medicine in 1928, where it remains a prominent feature to this day. Requests for Reprints: Stanley J. Reiser, MD, PhD, University of Texas Health Science Center at Houston, P.O. Box 20708, Houston, TX 77225. Current Author Address: Dr. Reiser: University of Texas Health Science Center at Houston, P.O. Box 20708, Houston, TX 77225.
Annals of Internal Medicine. 1990;114:902-907. References 1. Epidemics III. In: Jones WH, ed. Hippocrates. Volume 1. Cambridge, Massachusetts: Harvard University Press; 1923:279. 2. The art. In: Jones WH, ed. Hippocrates. Volume 2. Cambridge, Massachusetts: Harvard University Press; 1923:193, 203. 3. Sydenham T. In: Dewhurst K, ed. Dr. Thomas Sydenham (16241689): His Life and Original Writings. Berkeley, California: University of California Press; 1966:60, 127-8. 4. Morgagni GB. The Seats and Causes of Diseases Investigated by Anatomy. Volume 2. New York: Hafner Press; 1960:127-8. 5. Laennec RT. A Treatise on the Diseases of the Chest. John Forbes, trans. New York: Hafner Press; 1962:398-400. 6. Rodin AE, Key JE. Medical Casebook of Doctor Arthur Conan Doyle: From Practitioner to Sherlock Holmes and Beyond. Malabar, Florida: Robert S. Krieger; 1984:199. 7. Louis PC. Researches on the Effects of Bloodletting. Boston: Hilliard, Gray and Company; 1836:64-5. 8. Cannon WH. The case method of teaching systematic medicine. Boston Medical and Surgical Journal. 1900; 142:32. 9. Painter FM. Extending the influence of a hospital. The Modern Hospital. 1918;2:356. 10. Washburn FA. The Massachusetts General Hospital: Its Development. 1900-1935. Boston: Houghton, Mifflin; 1939:117.
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