The Evolution of Medical Research Writing

The Evolution of Medical Research Writing from
1735 to 1985: The Case of the Edinburgh

Medical Journal
DWIGHT ATKINSON
University of Southern California
A crucial event in the historical evolution of scientific English was the birth of
Downloaded from http://applij.oxfordjournals.org/ at University of Leeds on August 19, 2014

the scientific journal. This event, and its early rhetorical consequences, have
been well described in recent research. In contrast, few details are known con-
cerning subsequent developments in scientific writing from the eighteenth
century onward. In this paper, the changing language and rhetoric of medical
research reporting over the last 250years are characterized and the underlying
causes of these changes investigated.
Research articles from the Edinburgh Medical Journal, the oldest con-
tinuing medical journal in English, constitute the corpus in this study.
Sampling took place at seven intervals beween 1735 and 1985, with two types of
data analysis being performed: rhetorical analysis focusing on the broad genre
characteristics of articles; and linguistic analysis of these articles' registral
features using Biber's system of text analysis.
Results indicate that the linguistic/rhetorical evolution of medical research
writing can be accounted for on the basis of the changing epistemological
norms of medical knowledge, the growth of a professional medical community,
and the periodic redefinition of medicine vis-a-vis the non-medical sciences.
I. INTRODUCTION
The birth and development of English scientific prose is a compelling area of
research for both the historian of science and the student of written language.
This is due partly to the fact that, in response to the new rhetorical exigencies
created by the explosion of scientific activity in the seventeenth and eighteenth
centuries, whole new written forms—the research article and the scientific
journal—came into being (Kronick 1976), bringing with them new ways of using
the English language. Thus, Shapin (] 984), Dear (1985), and Bazerman (1988)
have demonstrated how a substantial part of the now-conventionalized
language and rhetoric of science was first introduced by such scientists as
Robert Boyle and Isaac Newton in the seventeenth century, in order to make
reports of their investigations more believable and persuasive to their develop-
ing reading public. And studies of more recent periods (for example, Bazerman
1984; Huckin 1987) show that, as the sciences have continued to evolve, so too
have the linguistic and rhetorical means by which they are primarily com-
municated.
Yet while this research has provided valuable insights into the development
Applied Linguistics, Vol. 13, No. 4 © Oxford University Press 1992
338 THE EVOLUTION OF MEDICAL RESEARCH WRITING
of written scientific discourse, it tends to have several limitations. The selective

focus of this work on two widely separated periods of scientific growth—the
period of initial activity in the seventeenth century and the contemporary
(twentieth-century) period—is one important limiting element. As a result of
this selectivity, we know almost nothing about the development of scientific
research writing for a period of almost 200 years. A second factor constraining
current research is the nearly total pre-occupation with examining the language
and rhetoric of the experimental sciences; what of those sciences—as widely
varying as biology and astronomy—which have depended significantly on non-
experimental methods of data collection? Yet a third limitation of recent work
on the evolution of scientific English concerns the types and levels of text

analysis employed; investigators have thus far relied largely on rhetorical or
literary text-analytic techniques, giving little detailed attention to the linguistic
or registral features of scientific text.
While such limitations are understandable given the deep interest in and
historical importance of certain periods and types of science, much work
remains to be done before an adequate description of the evolution of modern
scientific writing is possible. The research presented herein is a preliminary
effort to address some of these remaining gaps. More specifically, the present
study has as its goal an integrated linguistic and rhetorical description of the
written medical research article—represented in this case in a single historical
journal of medicine—as it has evolved from the birth of the modern medical
profession in the mid-eighteenth century (Loudon 1986) to the present day.1
2. DEVELOPMENT AND MODERN FORM OF THE SCIENTIFIC RESEARCH ARTICLE

While the evolutionary course of modern science and its means of literate
expression may seem in hindsight to have been natural and inevitable, such
appearances are deceiving.2 Both its present-day language and science itself are
the complex products of centuries of innovative epistemological, rhetorical, and
linguistic choices, chance events, and social and ideological forces (Fleck 1979;
Shapin and Schaffer 1985). Although the comparative weights and alignments
of these various historical influences are still far from clear, a general picture of
the early development of English scientific prose—and in particular the prose of
the journal research article—has begun to emerge in the work of Shapin, Dear,
Bazerman, and others.
Shapin's (1984) contribution to our understanding of the evolving scientific
prose form concerns the means by which the original English empiricists, led by
Robert Boyle, sought to ensure credibility for both their overall philosophy of
science and particular empirical results. According to Shapin, Boyle integrated
three 'technologies' of knowledge-production—the material, the social, and the
literary—in pursuit of these goals. In regard to literary technology, Boyle
advocated specific linguistic and rhetorical strategies in order to make the
experimental report a powerful mechanism of persuasion. One central strategy
was deliberate prolixity—the use of'ornate sentence structures, with appositive
clauses piled on each other' (Shapin 1984: 493) in exhaustive circumstantial
DWIGHT ATKINSON 339
descriptions of experiments. Shapin shows how such descriptions were a crucial

means of providing for 'virtual witnessing', i.e. the reader's vicarious experience
of actually being present at an experimental demonstration. Virtual witnessing
held far more promise as a tool of persuasion than other means, since there was
no theoretical limit to the number of people who might be so convinced.3
Other persuasive strategies advocated by Boyle consisted of the indexing of
modesty and caution in the narration of experiments, and clarity in the overall
organization of reports. In regard to the former, linguistic hedges were
introduced to show an appropriately cautious attitude toward interpreting
empirical experience. As Boyle explained in his Proemial Essay:

in almost every one of the following [experimental] essays I . . . speak so doubtingly, and
use so often, perhaps, it seems, it is not improbable, and such other expressions, as
argue a diffidence of the truth of the opinions I incline to, and that I should be so shy of
laying down principles, and sometimes of so much as venturing explications. (Quoted
in Shapin 1984:495)
Regarding attention to the second point mentioned above—organizational

clarity—Boyle advocated the crude sectioning of experimental reports (into
theoretical and non-theoretical parts) as a way of clearly separating empirical
fact from human speculation.
Dear (1985) provides a more general perspective on the origins of modern
scientific rhetoric and language, but one that has much in common with
Shapin's. Examining early articles in the Philosophical Transactions of the Royal
Society of London,4 Dear found in them a conventionalized rhetoric, formed
largely in opposition to the prevailing style of philosophical discourse. The
latter, best exemplified in the genre of written 'commentary' on a classical
philosophical text, depended critically on the citation of ancient or medieval
philosophers, since these philosophers' authoritative reputations were taken to
warrant arguments that could be shown to derive from their works.5
In opposition to this 'scholastic' approach, experimentalists like Boyle and
Newton championed a rhetoric of immediate experience. In this system, a
situated, concrete narrative event, as directly encountered and reported by the
experimenter, was elevated to the position of prime authority. The linguistic
indexes of this epistemological revolution were the use of first-person pronouns
and past-tense, active-voice verbs in the actual experimental or observational
narrative—details of circumstances surrounding the event were also typically
provided in profusion. These features are exemplified in Boyle's account of an
experiment on the properties of vacuums:
But when after this, the feathers being placed as before, we repeated the experiment by
carefully pumping out the air, neither I nor any of the bystanders could perceive
anything of turning in the descent of the feathers; and yet for further security we let
them fall twice more in the unexhausted receiver, and found them to turn in falling as
before; whereas when we did a third time let them fall in the well exhausted receiver,
they fell after the same manner as they had done formerly. (Cited in Dear 1985:152)
According to Dear, the persuasive power of accounts like Boyle's depended

wholly on the success with which they recreated 'a definite occurrence
happening to a particular person' (Dear 1985: 154). The narrator and his
situated experience thus became the epistemological touchstone of the Royal
Society, and first-person narratives of experiments and observations became
the sine qua non of its reporting style.
Bazerman (1988: chapter 3) studied the rhetorical evolution of reports of
scientific experiments in the Philosophical Transactions, from its establishment
in 1665 up to 1800. His basic findings were: (1) that experimental reports still
represented a definite minority of articles as late as 1800; (2) that experimental
articles evolved in successive stages from simple reports of events involving

minimal human intervention, into polemics using experiments to question
alternative reports of such events, into reports of experiments supporting
general theories or claims, and finally into presentations of more specific claims
and their evaluation by experiment; (3) that the reporting of experimental
methods and results became more detailed and precise as the article form
evolved—i.e. as the experiment tended to assume a greater role in scientific
argumentation; and (4) that the writers' attitudes toward the certainty of
empirical knowledge appeared to change as well at each stage of the article's
evolution. Although Bazerman did not explicitly investigate the linguistic
consequences of these developments, he does show that definite changes took
place at the level of rhetorical organization. Thus, in the first volumes of the
Philosophical Transactions, unelaborated natural observations—often related
second-hand by the editor, since the extracting of letters was a typical means of
contribution—were the favored type; but this quickly changed as authored
reports consisting of brief introductions and narratives of single experiments or
observations became the norm. In the next stage {circa 1700-60), the presenta-
tion of experiments became more systematic, as they developed into means of
adjudicating disagreements over the nature of controversial phenomena.
Around mid-century, the non-experimental, theoretical aspects of the articles,
which typically preceded the experimental descriptions, began to develop, and
by 1800, many articles were sequentially organized as: theory-*specific
hypothesis ^experimental trial-as-final proof, with conclusions occasionally
appended at report's end.
Finally, the current science-based research article has been provided with
perhaps its most complete rhetorical and linguistic description by Swales
(1990). For the purposes of the present study, the salient points of Swales's
discussion are here summarized:
1 Scientific research articles, far from being straightforward accounts of

laboratory findings, are complex conventionalized structures whose main
rhetorical function is to create belief in an audience with no direct access to
the empirical events being reported.
2 One way in which belief is created is through the conventionalized 'packag-
ing" of the research. Thus, the highly standardized Introduction/Methods/
DWIGHT ATKINSON 341
Results/Discussion (IMRD) structure is in one sense an attempt to provide

an objective appearance to an obviously idiosyncratic set of events.
The overall rhetorical structure of scientific research articles can be
described in terms of: (1) the level of conceptual abstraction at which the
individual IMRD sections operate; and (2) the linguistic correlates of the
IMRD sections. The levels of abstraction are graphically portrayed in Figure
1 (borrowed by Swales from Hill, Soppelsa, and West 1982), in which a lesser
width between vertically-oriented diagonals signifies a lower level of
abstraction. Linguistically, certain features tend to occur differentially across
IMRD sections, supporting the claim that these sections are primarily
functional in character. Thus, first-person pronouns, simple present tense,

and active-voice verbs (Heslot 1982), f/iaf-nominals (West 1980), and
modals and adverbs and adjectives of probability (Adams Smith 1984), tend
to occur in much greater proportion in the Introduction and Discussion
sections of research articles, while passives occur more frequently in the
Methods and Results sections (Heslot 1982). In-depth analysis of the
individual sections themselves (for example, Swales 1981; Crookes 1986)
tends to further corroborate their specialized rhetorical/communicative
functions.
Introduction
Methods
Results
Discussion
Figure 1
3. RESEARCH QUESTIONS
The research reviewed to this point gives arich,if partial, characterization of the
development and present form of English scientific research writing. To
summarize: (1) the research report, far from being the mere transcription of
empirical events, may best be viewed as an on-going, developing solution to a
rhetorical problem—how to convince those not directly privy to the events
under study that one's findings are accurate and meaningful; (2) various
solutions to this rhetorical problem have been innovated in recent centuries,
and, through time, some of these solutions have tended to become convention-
alized (Atkinson 1991a). This is not to say, however, that, once convention-
alized, such solutions are totally resistant to change—the evolution of the
scientific research article, if not proceeding smoothly, has none the less
continued; (3) the formal aspects of scientific writing are inextricably bound up
with the epistemology of science itself. Changes in scientific 'thought-styles'
(Fleck 1979; cf. Bazerman 1988; Kuhn 1970) are thus fully reflected in altered
styles of writing. In this regard, undoubtedly the biggest change in scientific
thinking to take place in the last 350 years has been the one championed by
Boyle and the Royal Society—an epistemological revolution which is indexed
by the innovation of the journal-based research article; (4) linguistically and
rhetorically speaking, the research article began as a straightforward narrative
of an experiment or observation, with the narrator (so to speak) at center stage.
First-person pronouns and past-tense active-voice verbs were the most salient
linguistic characteristics of early scientific writing, with hedges and prolix

circumstantial descriptions playing contributing roles. But as explicit theory
gradually assumed a more central position in scientific thought, research writing
became increasingly objectivized, impersonal, and organizationally modular.
These characteristics are most fully developed in the present-day scientific
research article.
Given this background of relevant research, four questions were chosen to
guide the present investigation:
1 Has medical research writing evolved over the past 250 years? If so, how can
this change be characterized using a combination of linguistic and rhetorical
analytical techniques?
2 To what degree does the portrait of the evolving scientific research article
given above parallel the description of medical research writing arrived at in
this study?
3 If these two descriptions are in fact similar, in what ways can the added detail
supplied by the present investigation—through its broader diachronic range,
more complete linguistic analysis, and focus on medical science—contribute
to our base of knowledge about the scientific research article?
4 If these two descriptions are found to differ significantly, wherein lie the areas
of difference, and to what source can these differences be attributed?
4. RESEARCH SUBJECT: THE EDINBURGH MEDICAL JOURNAL

The Edinburgh Medical Journal (EMJ) is the oldest English-language medical
journal still in existence (cf. Garrison 1934), having been published in various
forms and under various titles since 17 3 3 .fi The following is a brief summary of
its history, which is documented in depth by Couper (1908), Comrie (1932),
and Atkinson (1991b).
Under the influence of Francis Bacon, the collection of a massive data-base of
empirical observations and experiments was considered a pre-conditon for
medical/scientific advancement. The EMJ, initiated as the official publication
of a society of medical academics based in the University of Edinburgh, was
conceived largely as a contribution to the Baconian programme. This aim
paralleled an original goal of the Royal Society, and the EMJ's first volume was
dedicated to the president and members of that group. Appearing semi-
DWIGHT ATKINSON 343
regularly for much of the eighteenth century—during part of which it was

primarily a vehicle for book reviews—by the early nineteenth century the EMJ
was a major medical quarterly reporting clinical research and observations.
Throughout that century, when it acted as a forum for some of the leading
medical thought and debate of the time, the EMJ was considered a medical
journal of the first importance. Due to economic, social, and educational
factors, however, by the middle of the twentieth century the journal had lost
most of its former influence—at present its primary purpose is to publish
medical research done just within Scotland. This recent decline in fortunes,
however, does not diminish the journal's historical significance—for most of its
258 years the EMJ has been edited by eminent physicians and surgeons, and

numerous papers by the giants of modern medicine, including Liston, Simpson,
and Lister, have appeared there.
5. METHODS
Based on the very limited availability of older volumes, it was decided that the
EMJ would be sampled at forty- to forty-five year intervals across its 258-year
history. The years thus sampled were: 1735, 1775, 1820, 1864, 1905, 1945,
and 1985. Two types of text analysis were undertaken on the volumes published
in these years: (1) a focused rhetorical analysis of the form and content of all
'original articles' in the first bound volume from each year;7 and (2) a linguistic
register analysis of ten original articles per volume, employing the methodology
of Biber (1988). This combination of differing text-analytic methodologies was
motivated by a desire to provide a richer and empirically better-grounded
description of evolving scientific/medical research writing than has so far been
attempted.
At the first, or rhetorical level of analysis, the necessarily descriptive
methodology is not a favoured one in the field of linguistics. It is, on the other
hand, standard in thefieldsof rhetoric and literary studies. Following Bazerman
(1988: chapter 3), this approach consists of a detailed examination of the
subject texts by the researcher—an activity guided by a set of pre-formulated
questions focusing on text characteristics of immediate theoretical interest.8 In
the present study, these guiding questions were:
1 What different text-types or genres of medical writing are identifiable within
each sampling period? What are the formal and semantic characteristics of
these genres?
2 To what degree do these genre-types appear to be standardized, or
conventionalized, within each period?
3 What is the relation of theory to data in each of the articles examined? How
stable does this relationship appear to be within periods?
4 What are the principles of 'design coherence'9 (Phelps 1985) within articles?
To what degree do these principles appear to be conventionalized within
sampling periods?
5 Are there formal aspects of the articles which appear to be shaped by the set
of 'facts' or 'conventions for construing reality' (Bizzell 1982), which

constitute the discourse community's base of medical knowledge and
activity? That is, do there appear to be epistemological links between stan-
dardized rhetorical form(s) and content?
At the second, or linguistic level of analysis, the methods used were those
developed by Biber (for example 1988; Biber and Finegan 1989) for socio-
linguistic and sociohistorical register analysis. This 'Multidimensional' (MD)
approach to the analysis of language in use is based on four theoretical assump-
tions: (1) that linguistic registers derive their distinctive characteristics from
inherent co-occurrence patterns of linguistic features: (2) that these patterns may

be characterized for particular groups of texts as discrete numerical values on
underlying dimensions ofvariation—continuous, empiricially-determined scales
of variation on which a wide range of texts can be shown to differ significantly; (3)
that these dimensions themselves can be interpreted in terms of the social,
psycholinguistic, situational, and text-functional roles that their constitutive
linguistic features have been found to play in past research; and (4) that it is neces-
sary to characterize all text groups on multiple dimensions of variation, in order
to capture the complex nature of textual variability, five dimensions of variability
which Biber has identified in his research, and the relative positions of groupings
of contemporary text genres on these dimensions, are presented in Figure 2.
Taking the foregoing assumptions as a theoretical base, MD analysis relies on
computational and statistical tools to realize its goals. Computationally, MD
analysis uses purpose-written programs to automatically analyse large-scale,
computerized text corpora. Statistically, MD analysis uses the multivariate
statistical technique known as factor analysis (Gorsuch 1983). Factor analysis
places all linguistic features (as counted in the computerized text analysis) on a
limited number of different 'factors', according to the features' associated
frequencies of co-occurrence. These factors are then considered to represent the
above-mentioned dimensions of variation, which are subsequently interpreted in
light of the shared functions of the linguistic features the factor analysis has
grouped together. In the present study, thefivefactors used by Biber (1988) were
employed.10
Selection of the ten texts per period to be examined at the linguistic level of
analysis took place as follows. After an initial reading of all texts, a rough scheme
was devised for the purpose of characterizing the major types of diachronically
recurring original articles. Thefiveresulting text categories were: (1) narratives
of single cases of disease or injury (i.e. case reports); (2) summations of know-
ledge concerning specific diseases or conditions (hereafter, disease reviews); (3)
reports focusing on how to treat specific diseases/conditions (hereafter,
treatment-focused reports); (4) reports aimed at providing potentially applic-
able, experimentally derived medical/scientific information (i.e. experimental
reports); and (5) printed versions of speeches made to professional medical
groups on medical topics (i.e. speeches). All original articles found not to fit into
thesefivecategories were placed in a sixth, or 'other' category. Using this system
http://applij.oxfordjournals.org/ at University of Leeds on August 19, 2014
Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5
Informational Narrative Explicit Overt Abstract

Production Concerns Reference Persuasion Information
official documents
20 6 -general fiction 7 5 6
professional letters academic prose
official documents 6
15 - academic prose 5- 5 - 4 5 official documents
professional letters
biographies 4 _ academic prose 3 -editorials. 4 _
10 -editorials 4 - 3-
2 ~~ editorials; biographies 2 3
personal letters a
'IGHT AT
5 "broadcasts i 1 1 "general fiction 2
professional letters prepared speeches
0 prepared speeches
general fiction 0 "official documents
0 2 -biographies -1 1
prepared speeches academic prose professional letters *
-2 -
spontaneous speeches -1 _biographies 0 Z
en
1 1 Q
—J 1
prepared speeches —3"general fiction biographies
A personal letters; face-to-
*T
face conversations -2 -1 —
-10 - 0- -5 —
face-to-face conversations -6 _ -3 - _2 _ prepared speeches
< c i _editorials general fiction
— 13 —1 —7 -4 _ -3 _ personal letters
-8 — broadcasts face-to-face
-2 _ conversations
-20 —personal letters -9 -broadcasts -5 _ -4
professional letters
academic prose
Involved Non-narrative S ituation-dependent (No negative Non-abstract
-C
Production Concerns Reference pole) Information
Figure 2: Major dimensions of register variation, with mean factor scores for selected contemporary text genres (from Biber
1988)
of classification, the numbers of articles falling into each category for each
sampled volume/year were first calculated in terms of percentages of the total
number of original articles per volume. Next, these percentages were taken as
guidelines for the relative number of texts (out of the total of ten per period) to
be selected for analysis per text category per volume.11 Finally, the texts them-
selves were randomly selected from within each text category in each sampling
period. The 70 texts chosen in this manner totalled 186,553 words.
6. RESULTS
Part 1 of this section describes general patterns of rhetorical change across all

original-article types; part 2 then provides support for these generalizations in a
focused rhetorical analysis of the case report; part 3 presents general results of
the diachronic linguistic register analysis; and part 4 substantiates the findings
presented in part 3 via a concrete description of the changing language of the
case report.
6.1 Rhetorical level: Content and formal organization of original articles

Contentwise, original articles developed over the 250-year period of study from
concrete reports of very small numbers of specific medical events towards a
standard marked by abstractions from large numbers of such events. Thus,
whereas the most common article type in the eighteenth century reported single
cases of disease, those in the twentieth century focus on the treatment of, or
collection of information about a general disease type, supported by statistics
derived from large numbers of cases.
Accompanying this movement toward abstraction from large numbers of
cases, the author's 'place' in the discourse is also seen to change. Early medical
reports featured a prominent authorial persona, one clear index of which was
the pervasive use of / as subject in active verb constructions. This is only one
feature, however, in a rhetorical complex which placed the author squarely in
the discourse's midst; dynamic characterizations of the author's psychology-
worries, momentary failures, sudden decisions—and indications of his social
position vis-d-vis his readers are clearly conveyed in the early EMJ. Not until
the second half of the nineteenth century does this central authorial persona
begin to wane, to be gradually replaced by a non-author-centered style of
discourse.12 Typical signs of this latter development, beyond diminution of the
indexes of authorial persona mentioned above, are the increasing likelihood of:
(1) medical events to be described in quantitative or technological terms; (2)
these events to be summarized instead of described in detail; (3) accounts of
these events to be reconstructed second-hand from notes of other medical
practitioners; and (4) a much higher level of textual reference in EMJ articles to
other published work.
A third general area of change in the content of EMJ articles—their level of
conceptual integration—has a close correspondence to variations in their form.
Thus, in the eighteenth century, events are usually retold in sequential narrative
wholes; that is, early medical case reports tend to start at the moment an
DWIGHT ATKINSON 347
accident happened (or alternatively when the author arrived at the scene), and
end with the patient's recovery or death. By 1820, however, content discontinu-
ities have become common. Thus, articles in that year's volume frequently
consist of either two or more unrelated or loosely related case reports—each
with a clear beginning and end, but with little or no transitional material between
them—or complex collections of the work of several authors. By 1864, this
extreme fragmentation of content has ceased, although larger collections of
often loosely related cases have become typical. By 1905, most case material
has become substantially integrated into larger, more abstract discussions of
treatment and disease, but not until the 1945 volume is arrangement of texts
into conventionalized sections approximating the current EMRD norm found.

By 1985, however, this experiment-based system of text organization is so
dominant that even marginally scientific texts are sometimes placed in this
format.13
Finally, textual content changes directly reflecting shifts in medical theory are
evident across the EMfs history. Thus, beginning in 1775 the theoretical
approach known as humoral medicine motivated certain conventions of the
case report through the tenet that diseases, though of general kinds, are mani-
fested in each patient uniquely. This belief led to the customizing (from a
standard inventory of drugs) of a treatment regimen corresponding to individ-
ual patients' original symptoms, as well as their reactions to an initial standard
treatment. One textual reflex of this approach was a conventionalized series of
events in the latter part of the case report, as discussed below in section 6.2 and
illustrated in Figure 3. A second example of textual content changes directly
related to shifts in medical epistemology: the late nineteenth-century reconcept-
ualization of medicine on the model of laboratory science is reflected in the way
that abstract discussions of disease subsumed the detailed reporting of single
cases. This trend, culminating in 1985 in the virtual elimination of case material
from the central types of medical research writing, was one consequence of an
increasing interest in overarching medical generalizations, at the expense of
detailed, single-event observations.
Concerning developments of rhetorical form in the articles sampled, it should
first be re-emphasized that the highly conventionalized article format in the
current EMJ (i.e.jthat approximating the IMRD sequence) is not clearly evident
until 1945. Other organizational norms do obtain, however, at various periods
of the journal's existence. Thus, most articles in the 1735 volume consist of
unbroken narratives or descriptions of unitary medical events, although experi-
mental essays on the Royal Society model and longer 'systematic' treatises with
possibly pre-Royal Society roots also appear. At the same time, about half of all
original articles are in the form of professional letters to the journal's editor,
frequently with the salutation Dear Sir and elaborate greetings still intact. In the
1775 volume, continuous case narratives again predominate, but a stand-
ardized narrative 'content schema' (for which, see 6.2 below) begins to appear.
A parallel but weaker development in this period is the organization of articles
into rhetorical, purpose-based proto-sections, for example, a case narrative
followed by a post-mortem description, followed by a discussion of the case.

This latter trend shows further development in 1820, with graphical cues of
discrete report organization such as subtitles and inter-paragraph white space
appearing commonly for the first time—although some of the article 'sections'
thus organized are very loosely related. And the 'modularity' of articles con-
tinues to increase in the next two sampling periods, although now accompanied
by a shift in rhetorical emphasis from case narrative presentations to disussions
of their medical significance. By 1905 most articles containing case narratives
present them in much reduced form, as well as graphically separated from non-
narrative sections, and the de-emphasis of case material continues in 1945. By
1985, case-report features are virtually non-existent in the central article types,

i.e. large-scale investigations of general diseases and their treatment. Instead,
articles consist of abstract generalizations supported by statistical summaries of
characteristics of groups of patients—with numerical details presented in tables
complementing the written text.
6.2 Rhetorical form and content of the case report

The general patterns of evolution in the EMTs original articles are clearly
exemplified in the development of the case report—the one genre of medical
research writing which has been the common stock-in-trade of doctors over the
centuries (Fye 1987). In terms of content, case reports in the first two EMJ
volumes sampled are straightforward narrative accounts of either: (1) single
cases of unusual injury or disease;14 or (2) conditions/diseases treated with new
medical techniques. A typical example of the former is Text A in the Appendix.
The prominence in this article of descriptions of the author's own reasoning
processes, and to some degree of his emotions, was a characteristic of early EMJ
articles mentioned above.
In terms of form, early case narratives often exhibit features of professional
letters, such as salutations, encomiastic beginnings, and the use of you as a direct
address form. The initial paragraph of a 1735 case report displays all three
characteristics:
Gentlemen,
The good effects of your generous Concern for the Welfare of Mankind, are now
conspicuous in the many useful Observations and Essays that have been com-
municated to the Publick in your Collections, which without this Opportunity, would
probably never have seen the Light. At the same time I must think we are also greatly
indebted to you for the judicious Abridgement of the most considerable improvements
and Discoveries in Physick made through Europe, which most private Persons remain
entirely ignorant of, or it is very late before they are informed of them. It is owing to
your Second Volume that the specifick Virtue of the Cortex Peruvianus, in curing
Mortifications, was known early enough here to be put in Practice in the following
Case. (EMJ 1735:39).
By 1775, a conventionalized schema for case narratives has appeared, and
henceforth coexists with the less differentiated narrative style of 1735. This
DWIGHT ATKINSON 349
(1) GENERAL PATIENT INFORMATION (+ COMPLAINT STATEMENT):

(name), sex, (age), occupation/socioeconomic status,
(body build or physical constitution),
(immediate complaints)
I
(2) (PAST HISTORY/ORIGIN-OF-COMPLAINTS DISCUSSION-usually occurs
4
prior to point in narrative where author is called to see patient)
AL
(3) DETAILS OF AUTHOR'S ORIGINAL EXAMINATION OF PATIENT

(4) INITIAL TREATMENT REGIMEN AND ITS IMMEDIATE EFFECTS
(5) (SECOND TREATMENT REGIMEN AND EFFECTS - when initial treatment had no,
or negative, effects, or there were unexpected complications)
(6) SUBSEQUENT COURSE OF ILLNESS/CONDITION - often given in short or

minimal paragraphs with date headings
i
(7) MINIMAL NOTICE OF OUTCOME OF ILLNESS/CONDITION
Figure 3: Content schema for narrative case reports in the Edinburgh Medical
Journal / 775-C.1864 (note: parentheses enclose optional elements)
conventionalized 'content structure' (Meyer 1975) is diagrammed in figure 3

and exemplified in text B of the Appendix.
Although this schema is the most common content structure for case reports
in 1775, it is by no means the only form. Besides the earlier narrative form
mentioned above, a second alternative involves a two- or three-part division of
content—into a case narrative plus either an autopsy account or a series of
general remarks on the case, or both. By 1820, this trend toward greater text
division shows significant progress—case reports are now typically organized
(and sometimes explicitly divided) into sections serving different rhetorical
purposes. Text C of the Appendix represents a case report from 1820
constructed on a three-part pattern. The use of non-parallel sectioning cues, an
emphasis on pathological anatomy, and the relative underdevelopment of the
metadiscoursal 'Remarks' section single out this otherwise modern-seeming
report as a conventional product of its period.
As mentioned previously, articles in the 1820 volume are notable for their
lack of conceptual integration. Thus, case narratives are sometimes juxtaposed
with only loosely related non-case material, in what is presented in the EMJ as a
single article. 'Case of Hydrophobia originating without any obvious Cause' by
the surgeon George Ballingall is a typical example of this phenomenon. This
'complex text' begins with a letter to the EMTs editor introducing and
commenting on several cases; the letter is then followed by a short case
narrative. Both texts could easily stand alone, as indicated by the fact that they
are separately dated (with the dates over six years apart!). Another typical
combination of conceptually separate texts in this period consisted of two or
more tangentially related case narratives (once again independently dated) With
neither transitional material nor metadiscoursal generalizations tying them
together. This loose juxtaposition of cases appears to undergo significant
further development in the next period, resulting in what might be called the
'case collection'.
A case collection is a series of case narratives occurring side-by-side in an
article, but which do not necessarily have a close conceptual relationship.

Typically, these cases are embedded in little or no general theoretical context.
Some sense of the degree of integration of cases in 1864 case collections can be
obtained by briefly considering one or two texts: 'Notes of Interesting Cases in
Surgery' is a report of thirteen cases by a British doctor in India—eight of the
cases illustrate the author's preferred treatment for strangulated hernia, while
four cover surgery for bladder stones, and the fifth is entitled 'Removal of a
Splinter from the Fore-arm; Ligature of the Radial Artery'. 'Report of Clinical
Cases Treated in the Surgical Wards of the Royal Infirmary under the Care of
Mr Spence, during the Session of 1862-1863' is a collection of about 50 bare
case narratives, grouped according to the region of the body on which surgery
was performed.
Thus, by the second half of the nineteenth century, reports of multiple cases
are standard, although narrative presentations of the actual cases, rather than
their interpretations, still tend to predominate in the articles. By 1905, however,
cases are being used mostly as illustrations in more general discussions of
particular diseases and their treatment; and 'case reviews'—studies presenting
generalizations based on significant numbers of cases—begin to appear. This
trend continues in both the 1945and 1985 volumes, as the number of individual
cases analyzed per case review jumps dramatically. As a result, disease- and
treatment-focused reviews of fifty to one hundred cases are typical by 1985,
with generalizations being derived from case data via advanced statistical
procedures. Text D in the Appendix, a summary of 150 patients' experience
with blood clot on the brain, exemplifies the multiple-case review of 1985.
There are virtually no case details in this report; instead, patients are generalized
into various 'groups' (for example, 'over-65' and 'under-65' age groups) for
purposes of statistical analysis.15
6.3 Linguistic level: Overall results of diachronic register analysis of original

articles
Table 1 presents the results of diachronic register analysis of the EMTs original
research articles. Since the analysis here is of all genres combined within each
period, comparison of same-factor scores across time yields an overall profile of
diachronic register change in the EMJ.16
Regarding Factor 1 (plotted in Figure 4), the mean scores show a steady
increase from 1735 to 1985. Biber (1988) has interpreted this factor as
DWIGHT ATKINSON 351
Table 1: Mean factor scores for all EMJ original articles per period, and
measures of statistical significance and importance*1
Date N Factor 1 Factor 2 Factor 3 Factor 4 Factor 5
1735 10 6.43 3.15 1.02 -0.77 4.40

1775 10 7.03 4.26 1.43 -1.41 1.88
1820 10 9.31 2.33 3.65 -1.74 3.83
1864 10 10.47 0.26 2.84 -2.24 3.30
1905 10 12.00 0.14 4.83 -2.87 4.50

1945 11 14.47 -1.81 5.08 -1.70 4.17
1985 11 18.63 -1.75 2.90 -4.66 5.03
F value 14.46 5.23 2.45 3.78 1.81
P< 0.0001 0.0002 0.033 0.002 0.11
R-squared 53.9% 29.8% 16.6% 23.5% 12.8%
Figure 4: Mean factor scores for all EMJ original articles on Dimension 1:
Informational vs. involved production (parenthetical descriptors indicate similar
factor scores for selected genres from Biber 1988)
Informational Production
20
1985
15 (academic prose)
1945
1905
10 -1864
1820
1775
1735
(professional letters)
Involved Production
indicating an informational vs. involved production textual dimension—with

informational production denoting the planned communication of highly
integrated propositional content, versus on-line production of language with an
affective/interactive focus. Thus, nouns, longer words, prepositions, high type-
token ratios, and attributive adjectives co-occur in texts with positive Factor 1
scores, while such features as contractions, second-person pronouns, post-

verbal ?/*a/-deletion and private verbs (for example,/ee/, think) combine in texts
with negative scores. In terms of the EMJ, a steady increase across time in
Factor 1 scores indicates that what began as a set of discourse types functioning
moderately to communicate propositional content with precision, became all
the more focused on this purpose over the following 250 years. Thus, scores for
the eighteenth-century EMJ on this factor compare with those* of Biber (1988)
for modern professional letters (see Figure 4)—a moderately 'informational'
genre. In contrast, the 1985 score on Factor 1 compares with Biber's (1988)
score for modern academic prose—a category subsuming current medical/

scientific research writing.
Mean scores on Factor 2, interpreted by Biber (1988) as indexing narrative
vs. non-narrative concerns, also indicate a clear evolutionary trend in the EMJ
(see Figure 5).18 Beginning at a moderately 'narrative' level, original articles
become progressively less narrative over the course of the EMJ's history, with
one exception—the 1775 score reverses the trend by showing extreme
narrativity. But this score is almost certainly an artifact of the special constraints
in the 1775 volume on original research reporting—as mentioned above, the
EMJ in this period was mainly a book-review journal, with space for only short
narrative case reports. Thus, the Factor 2 score for 1775, while accurate as a
representation of the level of narrativity in the original articles of that period, is
not wholly comparable to those of other years.
Narrative Concerns
(adventure fiction)
5
1775
4
1735
3
1820 (biographies)
2
1
_ 1905/1864
0
-1
-2 _ 1945/1985
(professional letters)
Non-narrative Concerns
Narrative vs. non-narrative concerns
DWIGHT ATKINSON 353
Factor 3, on which three types of relative clauses, phrasal coordination, and

nominalizations are positively loading features, was interpreted by Biber (1988)
as representing explicit vs. sitution-dependent reference. Thus, texts with high
scores on Factor 3 tend to exhibit highly-specified endophoric reference.
Modern texts such as official documents, professional letters, and academic
prose—texts for which referential accuracy is a necessity—exemplify genres
with higher Factor 3 scores. Radio broadcasts and conversations, on the other
hand, have low scores, due to referential dependence on the listener's
knowledge of immediate context. In the EMJ's case (see Figure 6), scores begin
at a low positive level in 1735, move steadily toward the explicit-reference pole
until 1864—when they temporarily reverse directions—then resume upward

movement until 1985, when the score drops back to a moderate positive level.
Although there is no obvious explanation for these period-to-period perturba-
tions, a general trend toward higher levels of explicit reference over time is clear.
Explicit Reference
1945
1905
(academic prose)
1820
1864/1985
(biographies)
1775
(spontaneous speeches)
1 (- 1735
Situation-dependent Reference
Explicit vs. situation-dependent reference
The fourth factor, designated overt expression ofpersuasion by Biber (1988),

is the only dimension with a single pole. Modals,to-infinitives,suasive verbs and
conditional subordination co-occur in genres with a high score on this
dimension—but these are not prevalent features in any of the EMJ volumes
sampled. In fact, mean factor scores are below zero from 1735 onward, with
progressive movement away from the positive pole (see Figure 7). Thus, each
period has even fewer of the above-mentioned linguistic features than the one
preceding it. The one exception to this rule is the 1945 article sample, which
Overt Expression of Persuasion
(prepared speeches)
1735
1775
1820/1945
-2

1864
-3 1905
1985
-5
Figure 7: Mean factor scores for EMJ original articles on Dimension 4: Overt
expression of persuasion
regresses toward the 'overt persuasion' pole. This anomaly may relate to the
idiosyncratic nature of the 1945 sample—speeches constituted nearly half the
original articles. Since medical research was severely curtailed in Britain by the
end of World War n, the expedient of filling the EMJ with speeches made to
medical groups may have been in effect at this time. According to Biber's (1988)
findings, modern speeches generally have a low positive score on the overt
persuasion dimension; it is thus possible that the numerous speeches in the
1945 sample have biased its score in the direction of 'overt persuasion'.
Finally, Factor 5—designated abstract vs. non-abstract information—is the
only factor on which EMJ texts as a whole do not show a clear or statistically
significant pattern of variation. This finding is itself of interest because it is widely
believed that scientific language has become gradually more 'objectified'/
passivized over time (cf. Halliday 1988). Yet scores for Factor 5, on which
passives and reduced relative clauses are some of the main positively loading fea-
tures, show little diachronic variation. Only texts from 1775 demonstrate any
substantial variance from the cluster of scores at the 'abstract' end of this
dimension—a difference which may be attributed to the unusual nature of the
1775 text sample (for which, see above). It can therefore be concluded that
original articles in the EMJ are generally abstract and technical throughout the
journal's existence.
6.4 Diachronic register variation in the case report

Table 2 presents results of genre-specific analysis of the case report—the most
commonly occurring article type across the EMTs history. In most instances,
DWIGHT ATKINSON 355
Table 2: Mean factor scores for case reports genre.and measures of statistical
significance and importance
Date N Factor 1 Factor 2 Factor 3 Factor 4 Factor 5
1735 4 6.03 6.45 2.16 -3.17 3.35

1775 8 7.45 3.87 1.54 -1.27 1.73
1820 5 9.46 2.91 1.35 -3.11 3.67
1864 3 10.03 0.91 -3.36 -3.23 1.95
1905 1 12.36 -0.06 7.43 -6.95 1.76
1945 1 18.65 4.33 -0.58 -5.39 2.02

1985 5 17.60 2.57 4.62 -5.86 3.12
F values 3.9 0.9 5.8 2.7 0.6
P< 0.009 0.50 0.001 0.039 0.73
R-squared 51.4% 20.0% 61.1% 42.7% 13.9%
the developmental trends found for original articles overall hold as well for case
reports. At the same time, the trends seen here are substantially less linear than
those found in section 6.3 above, and in any case the smaller sample sizes do not
permit strong generalizations. The main purpose of the present section is,
therefore, to concretely illustrate some of the overall trends. Differences
between register-analysis results for case reports and original articles as a whole
will also be discussed where they appear substantive.
As seen in Table 2, scores for Factor 1 (informational vs. involved produc-
tion) show the same pattern of evolution as found for original articles overall in
this dimension. Thus, texts become progressively more 'informational' and less
'involved' over time, until they reach an extreme level of informational produc-
tion. The one exception to this trend is the factor score for 1985. This score,
however, is not a major exception—it still approaches the level of informational
production shown for texts overall in this period.
A side-by-side comparison of early and late case-report texts concretely
demonstrates the general trend over time toward the informational production
pole of this dimension. The extracts below show the beginnings of case reports
taken from the 1775 and 1985 volumes, respectively. In each, the positively
loading 'informational' features are printed in bold, while the negatively loading
'involved' features are printed in italics
1775
One of the men belonging to the 14th regiment had his breast violently squeezed
against a manger, by a vicious horse which he was dressing in the stable. When / saw
him, which was about ten minutes after the accident, he complained of violent pain in
the breast, which extended to each side, and of a difficulty in breathing. On examining
the sternum, I found it fractured transversely, immediately above the joining of the
cartilages of the fourth ribs. A grating noise was distinctly heard at the fracture, both
at the time of inspiration and expiration; and the solution of continuity was still more
evident on handing it; at the same time, the extremity of the one fragment did not rise
above the other.
1985
In a patient with proven chronic duodenal ulceration the development of a metabolic
alkalosis due to recurrent vomiting of undigested food suggests a diagnosis of pyloric
stenosis or gastric outlet obstruction at the level of the pylorus. The case described
below illustrates the importance of considering obstruction at levels other than the
gastric pylorus when the radiological evidence appears to refute the clinical diagnosis.
Case history
A 49-year-old former taxi driver was admitted with a one-month history of anorexia
and a four-day history of nausea, repeated effortless vomiting of partially digested

food, and epigastric discomfort. Over the previous ten years he had experienced many
episodes of localized epigastric discomfort relieved by proprietary antacids but had
not sought medical advice for this problem.
While both texts have substantial numbers of nouns and prepositions, they
are markedly more frequent in the 1985 text. Further, the prevalence of heavy
noun phrases makes the latter text much more 'nominal' (Wells, 1960) and
informationally dense. In regard to 'involved' features, neither article displays
them in abundance, but they occur about twice as frequently in the 1775 article.
Significantly, the 1985 sample contains as much «o«-narrative metadiscourse
as it does narrative text—a proportion which holds for the report as a whole-
while the 1775 report is virtually wholly narrative. In addition, even both
reports' narrative sections appear to exhibit different frequencies of 'informa-
tional' features.
Scores on Factor 2 {narrative vs. non-narrative concerns) again exhibit the
same general pattern as for texts overall on this dimension; case reports, how-
ever, show less variation. Disregarding scores from 1864-1945 due to their
small sample sizes, the remaining scores for case reports can be seen to fall
approximately four standard deviations in value over time, versus a six-point
range for the overall scores. This narrower range of variation—and the moder-
ate degree of narrativity still exhibited in 1985—are to be expected from a text
type which is fundamentally narrative. The two beginnings of case reports in the
extracts below illustrate the comparative distribution and frequency of 'narra-
tive' features (in bold print) on Factor 2 for the first and last sampling periods in
this study.
As might be expected, somewhat similar distributions of 'narrative' features
are evidenced in the 1735 and 1985 text samples. The main difference is that the
narrative in the earlier text is in a sense more prototypical in that it is more
detailed and concrete. The 1985 text, on the other hand, begins with a markedly
'nominal' summary, although even this summary is basically narrative. The
other notable difference between these samples is in the frequency of detached
participial clauses in the 1735 report (for example, the bulk of her belly ...
increasing). Detached participial clauses were a pervasive feature of early
medical research writing, and apparently of other types of eighteenth-century
prose as well.19
DWIGHT ATKINSON 357
1735
In June 17261 was desired to visit a woman betwixt forty and fifty years of age, who had
laboured under a hydrops ascites some years, and in that time had taken a great many
medicines by the direction of a physician. The most powerful diuretics and hydragogue
purgatives were given by another physician and me in vain, the bulk of her belly, which
was very great when I saw her first, rather increasing; so that at length, despairing of
doing her service by medicines, and she refusing to undergo the paracentesis, we gave
over prescribing for her.
Having one day taken a pretty brisk purgative, she told me that the water oozed at
her naval: This oozing continued constantly after, but was slow and gentle, giving her
no other uneasiness than what was occasioned by wetting her linens. She remained in

this state all the winter, without her belly increasing, but her flesh and strength wasted.
1985 .
Thiamine deficiency may present acutely as cardiac failure (wet beri-beri), or as the
Wernicke-Korsakoff syndrome. Wet beri-beri developed in two heavy beer drinkers in
Glasgow and both responded well to intravenous thiamine; one had a marked
metabolic acidosis, buit it was not stated whether this was a lactic acidosis. Proven
lactic acidosis responsive to thiamine has also developed post-operatively in a patient
fed on thiamine-free intravenous solutions during the preoperative period. The patient
herewith reported was admitted with severe lactic acidosis, hyponatraemia and some
of the features of the Wernicke Korsakoff syndrome. On treatment with intramuscular
thiamine the lactic acidosis rapidly disappeared.
Case report
J. W., a 49-year-old male, had been drinking beer and lager (but no spirits) excessively
for many years (confirmed by his wife). He had been eating poorly for sometime but
particularly in the last three months his food intake had been very poor and he was
losing weight. For three weeks he had been short of breath and during the 24 hours
prior to admission the breathlessness had become much worse.
Factor 3—explicit vs. situation-dependent reference—is difficult to interpret in

regard to its period-to-period variation. Leaving aside, however, the periods
1864-1945 due to their small sample sizes, Factor 3 score differentials do
suggest a trend. That is, a relatively low level of explicit reference through 1820
gives way to a moderate level in 1985. A similar pattern obtains for overall
scores on this factor, to the extent that later scores are generally higher than
earlier scores—but the overall 1985 score on this factor is markedly lower than
its immediate predecessors (cf. Table 1 and Figure 6). It is hoped that further
research based on a larger sample of case reports will permit sound generaliza-
tions to be made regarding this factor; at present, the small sample size and non-
linear patterning of scores rule out further interpretation.
Case-report scores on Factor 4 (overt expression of persuasion) represent the
following pattern: texts in the first four sampling periods have significantly
smaller negative scores as a group than do those in the final three periods. That
is, early case reports are closer to the 'persuasive' pole of the dimension,
although they are not particularly persuasive. While small sample sizes again
preclude stable inferences regarding this trend, a similar pattern is also found
for the overall scores on this dimension. The extracts below illustrate this
developmental trend with representative text samples from 'Remarks' sections

of 1775 and 1985 case reports. Bold print denotes 'persuasive' features.
7775
The concluson I would draw from hence is this; in all cases of poison it is prudent
immediately to give a solution of an alcali, followed by a vomit. If the poison be
corrosive sublimate, an alkali, eitherfixedor volatile, will decompose it, and precipitate
the metal in a form nearly inoffensive. It will have a similar effect on the sugar of lead,
the extract of lead, or on any metallic salt. If the poison be arsenic, Neumann observes,
that "Alkalies will very plentifully dissolve it." And if so, as it is difficultly soluble in
water, the vomit will then succeed the better to discharge it. Whether or not sulphur,
exhibited in any form, might lessen the danger of arsenic is not clear, though these two,

when united, are not poisonous. If the poison be of the vegetable class, an alkali can be
of no disservice, nor interfere with the other means of remedying by evacuatipn, nor yet
by the subsequent use of acids, so strongly insisted on by Tissot, as counteracting the
effects of narcotics; since acides given together with alkaline salts, are pronounced to
be attended with great success in this case, by Dr Mead and others.
1985
Vasa Praevia has been defined as a condition wherein the umbilical vessels
unsupported by the umbilical cord or placental tissue cross the fetal membranes in the
lower uterine segment and below the presenting part.
In his review of vasa praevia in 1952 Torrey was able to report fewer than 100 cases
in the literature since Benckisser first described a case of ruptured vasa praevia in
1831. Kouyoumdjian reviewed a further 52 cases to 1980.
The definitive diagnosis, antepartum, of ruptured vasa praevia can be made by
detection of fetal blood. This can be done using the methods of Klewihauer or Apt, and
rely on alkali denaturation of adult haemoglobin.
Diagnosis requires a high index of suspicion. Kouyoumdjian records antenatal
diagnosis in only 31 per cent and if fetal blood loss occurs the mortality rate has been
reported as between 73 per cent and 87 per cent.
In conclusion vasa praevia is an uncommon but serious complication of pregnancy
which most obstetricians will meet infrequently. A high index of suspicion is necessary
for its diagnosis and only thereby will a reduction in the high fetal mortality rates be
obtained.
Since both texts above have essentially the same rhetorical function—to
discuss and draw inferences from a previously related case history—the
linguistic characteristics of both texts should be highly comparable. The differ-
ence is that while the frequency of 'persuasive' features is low in both texts, the
1775 sample has about three times more than the 1985 sample.
Finally, Table 2 indicates that case reports do not systematically vary from
period to period on Factor 5, the abstract vs. non-abstract information
dimension. This is the same finding made in the overall analysis of texts sampled
in the present study. The conclusion to be drawn from the presentfindingis also
substantially the same as that made in the overall analysis: that here at least is
one linguistic dimension on which medical texts have varied little over the past
two and a half centuries.
DWIGHT ATKINSON 359
7. DISCUSSION
To answer immediately the first research question posed in this study, the
Edinburgh Medical Journal has undergone extensive textual evolution over its
two and a half centuries of existence, as illustrated above. Given this fact, an
attempt must now be made to answer the remaining research questions. These
can be slightly reframed as follows. First, to what extent do the changes in
medical research writing described here articulate with those found in scientific
writing by Bazerman, Shapin, and others? Second, what were the forces and
conditions underlying the characterized change—that is, why did research
writing in the EMJ develop as it did?

Regarding the development of medical vis-d-vis scientific research writing
over the last 250 years, there are definite areas of similarity and difference. First,
both types of writing were established on a common social and epistemological
base, and this fact had significant linguistic/rhetorical consequences. The
common base was, of course, the natural philosophy movement founded by
Francis Bacon. The combined work of Shapin (1984; Shapin and Shaffer 1985),
Dear (1985), and Bazerman (1988) provides a clear and plausible view of the
direct literate effects of Baconian science in the later seventeenth century, and—
in Bazerman's case—beyond. This approach to science was overwhelmingly
observational and 'empirical', finding its written expression primarily in the
personal narrative mode. This latter characteristic was unquestionably related to
the medium in which early scientific research happened to be communicated—
the professional letter—but this alone does not explain the utility of the narrative
mode to early modern science. As Bazerman found in reviewing the first 135
years of the Philosophical Transactions, the epistolary form of early scientific
research reporting was relatively short-lived, while its basic narrative structure
was retained up to the nineteenth century.
A similar course of development is seen in medical research writing. As stated
in the preface to the EMTs first volume, the, journal's modus operandi was to
collect observational accounts of natural/medical experience from a network of
correspondents, in the service of establishing for medicine a solid empirical
knowledge-base. As a consequence, original articles in the eighteenth-century
EMJ were typically narrative reports of single cases, often presented in
epistolary form. As shown above, narrativity—both linguistically and rhetori-
cally defined—became a progressively rarer phenomenon across the EMTs his-
tory; but it was clearly the main early mode of literate expression.
Probably inseparable from the narrative character of early scientific/medical
research writing was its emphasis on human actors—especially the author. As
Dear (1985) has demonstrated, the approach to written expression taken by
Boyle and the Royal Society was innovated in opposition to the abstract,
system-building discourse of academic philosophy. The persuasive power of
natural philosophical narrative therefore depended significantly on its 'here-
and-nowness', i.e. its concrete and personalized quality. This 'rhetoric of
personal experience' is also patent in the EMJ, from its inception well into the
nineteenth century. The particular tenacity of this form of discourse in the

medical world may have had its own special causes, quite apart from its use as a
tool of Baconian science—this aspect of medical narrative is discussed below.
But it can be said here that a definite correlation is apparent between the lack of
development in this early period of'research networks' (Ben-David 1960), and
the rhetorical prominence of the individual author-researcher.
A second area of comparison between early scientific and medical research
writing concerns the development of its «o«-narrative elements. Bazerman
(1988: chapter 3) points out that metadiscoursal aspects of experimental
articles in the eighteenth-century Philosophical Transactions were under
continuous development around a narrative/experimental core. By the nine-

teenth century the rhetorical emphasis in such articles had substantially shifted
to these theoretical discussions. A similar pattern obtains for research writing in
the EMJ. Although non-narrative aspects of articles were found to show maxi-
mum growth about a century later than in scientific writing, there was metadis-
coursal development of medical case reports beginning as early as 1775. By
1905, case material was being restricted to either truncated summaries in larger
discussions of disease and its treatment, or to the beginnings of articles which,
while nominally reporting single cases, were more concerned with their theoret-
ical importance and with embedding them in a larger literature.
The broad similarities of medical and scientific research writing up to around
the end of the eighteenth century are relatively easy to discern. Beyond that
point clear relationships are much harder to establish, due to the general lack of
scholarship on this period. Turning to the twentieth century, the large amount of
research on current scientific writing, and several studies on its development in
the present century, make comparisons at least a possibility. Bazerman (1984)
studied twentieth-century changes in articles on experimental spectroscopy in
one well-known physics journal, the Physical Review. Compared to their
modern counterparts, articles written at the turn of the century were relatively
short and much less nominal, with less technical lexicon, and low numbers of
bibliographical citations only loosely related to the reported research. Prior to
1900, the journal had emphasized the problem-statement and literature-review
functions of research articles, while in the first three decades of the twentieth
century, experimental methods and results became the rhetorical foci. Only
after 1930 were results regularly discussed and interpreted in articles, as
theoretical arguments began to come to the fore. Bazerman attributes these
developments to the growth of a research community based on a shared theory
of physics (i.e. quantum mechanics). In its evolution, the physics research article
thus directly reflected the changing epistemological situation in that field.
Medical research writing in the EMJ underwent its own series of profound
developments around the turn of the present century, although they only partly
parallel those found by Bazerman. In the British medical world, the notion of
laboratory-based 'experimental medicine' advocated by Bernard, Pasteur, and
Lister was having a demonstrable effect on how medical research and
education, and (to a lesser extent) clinical medicine were conducted. Thus, the
DWIGHT ATKINSON 361
de-emphasis of case material—seen clearly for the first time in the EMTs 1905
volume—was a revolutionary rhetorical development; it marked the first time
that single cases were not the units around which all other text was structured.
And while cases were still commonly reported in the articles of this period, such
accounts were severely circumscribed. This trend continued in 1945 and
1985—to the point that, by 1985, virtually all case descriptions were excluded
from the central/most frequent types of medical research writing.
It is important to note that the linguistic register analysis undertaken in the
present study does not appear to be sensitive to the enormous textual changes
which took place between 1864 and 1905. While rhetorical analysis indicates

strong textual correlations with this 'paradigm shift' to a new medicine, register
analysis shows steady but gradual textual evolution, toward a norm marked by
high dimension scores for informational production and explicit reference, and
moderate-to-high negative scores for narrativity and overt expression of
persuasion. How can this apparent contradiction between the two levels of
findings be resolved?
Closely related to and probably subsuming the epistemic shift toward
'scientific' medicine is a broader, more gradual evolutionary dynamic. This is the
movement from a relatively non-professionalized, individual-centred, and
privately-based medicine, to one which was highly professionalized, group
centred, and public?0 Medical practitioners in eighteenth-century Britain
constituted loosely-knit, mixed groups of amateurs and professionals. Thus, one
of the many social roles served by the clergy and landed gentry in this period was
that of community doctor—as late as the nineteenth century, practitioners with
formal medical training were the exception rather than the rule in Britain
(Loudon 1986). Similarly, medical practice was overwhelmingly private
practice—those who could afford medical treatment were generally attended to
on a one-to-one basis in their homes. Recent historical scholarship (for
example, Durey 1983; Jewson 1974) has also emphasized a third variable
affecting medical practice in this period—the relative power of the patient in the
doctor-patient relationship. Given the eighteenth-century medical commu-
nity's intense free market' character, as well as the practitioners' social
inferiority to much of their clientele, patients are believed to have exerted con-
siderable influence over the general approach toward and even specific treat-
ment of their medical problems. As a result, doctors expended much effort
learning about and treating the constitutional idiosyncracies and individual
symptoms of their patients, and they responded to their patients primarily as
individuals as well.
If this view of eighteenth-century medical practice is at all accurate, then it
would appear that medical societies like the one founded in 1731 in Edinburgh,
and publications like its EMJ, were diametrically opposed to the dominant
forms of medical practice. For the mission of the society and its journal was an
overwhelmingly public one—to foster the exchange of medical knowledge
throughout the British Isles and beyond, and in so doing to help establish a
comprehensive medical database, and perhaps a unified medical discourse
community. By the early-to-mid-nineteenth century significant long-term

effects of this broad 'publicization' of medical knowledge and practice could be
seen. Medical journalism was by then enjoying its first wave of popularity in
Britain, practical medical education was becoming formalized, and large public
hospitals were springing up in the large cities. Yet a fully public, profession-
alized medicine was still in the future. The paradigmatic shift to scientific
medicine at the end of the nineteenth century may have been just the crucial
development in this chain of events.
I would like to suggest that this movement from private to public medicine
may have had momentous consequences in terms of the changing language and
rhetoric of the medical research article. The favored form of communication in

the early EMJ was the letter-like narrative. Although it had ties to the
experimental essay innovated by Boyle, it did not break radically with a pre-
built written form—the professional letter. Only by virtue of a gradual shift from
individual-centred, non-professionalized medicine did a medical discourse
come into being which was not itself individually-oriented or written to be read
by an audience varying widely in terms of professionalization. Rather, a type of
writing was gradually evolved which was purpose-built to the needs of the
medical community. This new style of discourse was basically non-narrative, as
well as being more highly planned, informationally dense, and referentially
explicit than its predecessor.
This dynamic of textual evolution may also be viewed as attention to shifting
discourse norms. The personal narrative was the norm in the early EMJ, its
adoption predicated on its pre-existence, and on the fact that it was compatible
with the individual and private nature of medical practice. Thus, the practitioner
is represented in early case reports as an agent single-handedly grappling with
the patient's infirmity. The textually-constituted environment is basically
peopled only by the practitioner and the patient, and the power and persuasive-
ness of the written account depends on how well it captures a realistic individual
experience.21 This discourse norm underwent a subtle evolution between 1775
and 1864 due to the changing conditions of medical treatment and research. By
1864, the new or adjusted norm appears to have been based on the notion that
medical progress depended on the collection of multiple instances of similar
medical events—as advocated in the 'pathological anatomy' approach to
medicine innovated earlier in France. This perspective had itself evolved hand-
in-hand with notable medical innovations such as the large general hospital, and
the advent of the hospital also functioned to reconfigure medicine. As a direct
result, medical practitioners were increasingly working together in a common,
public space. In addition, the commitment to a medicine of multiple cases
entailed the construction of complex community research networks—for a
doctor to obtain on his own the large number of case experiences needed to do
this kind of research was virtually impossible.
By 1905, the multiple-case norm had undergone significant further evolution.
The knowledge accumulated via the comparison of large numbers of cases was
for the first time permitting empirically-based models of disease and treatment.
DWIGHT ATKINSON 363
Texts in this period fully reflect the new-found possibility of case-based

theoretical generalization, and their authors seem almost childlike in their
enthusiasm for exhaustive case/literature reviews. As a result, the individual
narrative was demoted to a marginal textual status. And by 1985, the new norm
had evolved to the point where case-derived statistics completely displaced case
details as the basis of medical persuasion.
CONCLUSION
Although the findings of the present study do not lend themselves to simple
integration and interpretation, it is perhaps by approaching them from a
macroscopic viewpoint—as I have tried to do here—that they gain some

significance. Looked at in this way, the linguistic and rhetorical analyses
complement each other in suggesting that the evolution of medical research
writing has been a gradual and continuous process, rather than a series of
changes based on revolutionary and drastic 'paradigm shifts'. This view differs
substantially from that taken by numerous historians on the development of
modern science and medicine in general; it stands, as well, in contrast to at least
some scholarly assumptions concerning the development of scientific/medical
prose. Aside from influencing such beliefs, it is hoped that historical research of
the type presented here will temper calls for linguistic reform of current
scientific and medical research writing, by fostering the realization that such
writing is part of an organic 'form of life', rather than simply a tool of scientific
communication.
(Revised version received January 1992)
ACKNOWLEDGEMENTS
Parts of this paper were presented at the 1 Oth Annual Meeting of the American
Association for Applied Linguistics, held March 22-24, 1991 in New York
City.
The research on which this paper is based would not have been possible
without the help and encouragement of Douglas Biber. I would also like to
acknowledge the generous aid of Charles Bazerman, Edward Finegan, Robert
Kaplan, Yumiko Kiguchi, David Morse (of the USC Norris Medical Library),
Lisa Spalding, and John Swales. Texts were obtained with the assistance of the
British Museum and Henry Huntington Library.
NOTES
1
The assumption made here—that medical and scientific research writing constitute a
single historical discourse tradition—is partly a pragmatic one. Since it is necessary to
situate inquiry vis-a-vis an established body of knowledge—but research on the history of
medical research writing is virtually non-existent—the assumption of the basic unity of
medical and scientific writing provides an intellectual context in which the study of the
former may be conducted. In this sense, the identification of medical with general
scientific research writing represents a working hypothesis in the present study, on the
basis of which it may proceed (cf. question 2 in the section of this paper entitled 'Research
Questions')
2
According to Shapin (1984:482):
the difficulties that many historians evidently have in recognizing this work of
construction [of the norms of science by chance events and innovative choices] may
arise from the very success of that work; to a very large extent we live in the
conventional world of knowledge-production that Boyle and his colleagues amongst
the natural philosophers laboured to make safe, self-evident and solid.
Gee (1990) sees the tendency towards blindness at the conventionality and hidden
assumptions of 'Discourses' (including 'Dominant Discourses' like that of science) as a
universal trend among the communities which constitute them. In Gee's words:
'Discourses are resistant to internal criticism and self-scrutiny since uttering viewpoints

that seriously undermine them defines one as being outside them' (1990:144).
3
The other major methods of persuading individuals of the validity of experimental
results were by providing either for the direct witnessing of experiments, or for the
experimental replication of such results. Concerning the latter, however, Shapin and
Schaffer (1985) show that few of Boyle's experimentalist contemporaries had the
wherewithal to replicate his experiments. One reason for this was that Boyle's pneumatic
air-pump—a nearly prehistoric vacuum device which played a crucial role in many of his
experiments—was practically one of a kind in the second half of the seventeenth century,
but there were other reasons as well. It may also be thought that, while replicating certain
types of experiments was a near-impossibility in Boyle's time, today's scientists find
replication generally unproblematic. This notion has been seriously questioned by
sociologists of science (for example, Knorr-Cetina 1981; Gilbert and Mulkay 1984), who
quote modern scientists to the effect that replication is in most instances an ideal concept,
with no realistic possibility of being performed. Additional (though circumstantial)
evidence for this claim is given by Huckin (1987), who notes the tendency of modern
scientific journals to demote article 'Methods' sections to marginal textual positions, or in
some cases to do away with them altogether.
4
The Royal Society of London was probably the first scientific society in the modern
sense, and has certainly been the prototype for most others in the English-speaking world
and elsewhere that succeeded it. Boyle, Newton, Halley, and Hooke were all founders or
early members of the society, which was formally chartered in 1662. The Society remains
active in the present day.
5
Such discourse took as its starting point a premise set forth by an ancient or medieval
authority, then proceeded to argue by deductive philosophical methods until a theoretical
position vis-a-vis this premise had been proven or disproven.
6
Thus, the journal was known as Medical Essays and Observations from 1733 to 52,
Essays and Observations, Physical and Literary from 1754 to 71, Medical and Philo-
sophical Commentaries from 1773 to 95, Annals of Medicine from 1796 to 1805, Edin-
burgh Medical and Surgical Journal horn 1805 to 55, Edinburgh Medical Journal from
1855 to 1953, and Scottish Medical Journal from 1954 to the present. According to
Kronick (1976) it was common practice among editors of early journals to frequently
change the journal's names; this practice has continued up to the present (Fye 1987).
7
'Original article' is a current standard designation for medical research reports which
encompasses the report-types which are thought to be generically central to the field.
Since this term actually occurs only in comparatively recent journals—although the
concept is clearly much older (Kronick 1976)—original articles for earlier periods were
operationally defined as follows: all articles to which authorship was attributed in the
1735 volume; all articles appearing in the 'Medical Observations' sections in the 1775
DWIGHT ATKINSON 365
volume; all articles which appeared in the 'Original Communications' sections of the
journal volumes from 1820,1864,and 1905; all articles appearing in the first (unheaded)
section of the 1945 volume. Original articles in the 1985 volume appeared in a section of
the same name.
8
Analysis at this level is further informed by a broad acquaintance with the rhetorical
aspects of the genres under study (gained only through extensive reading in these genres),
as well as with the histories of their parent disciplines/discourse communities.
9
Phelps (1985:23) defines 'design coherence' as the 'fully realized and relatively fixed
coherence [of a text] as a meaning object'. Thus, design coherence is largely a function of
the top-level 'architectural' structure of the written text, as opposed to more local
coherence-maintaining devices such as cohesion markers, which Phelps characterizes as
contributing to a sort of on-line, or 'flow' coherence.

10
Interested readers are referred to Biber (1988: chapters 4 and 5) for a fuller
discussion of the procedures by which these factors/dimensions are constructed.
1
' The following table summarizes the numbers and percentages of original-article
texts per text category which were chosen for analysis in each sampling period.
Date Case Disease Treatment Experiment Speech Other

report review
1735 4 (42%) 0 (0%) 2 (12%) 1 (8%) 0 (0%) 3 (39%)*

1775 8 (86%) 0 (0%) 1 (4%) 0 (0%) 0 (0%) 1 (11%)
1820 5 (50%) 1 (7%) 2 (15%) 0 (0%) 0 (0%) 2 (28%)
1864 3 (34%) 1 (14%) 2 (14%) 1 (3%) 1 (9%) 2 (26%)
1905 1 (10%) 2 (13%) 2 (23%) 1 (7%) 1 (16%) 3 (32%)
1945 1 (5%) 1 (10%) 1 (10%) 2 (12%) 4 (46%) 1 (17%)
1985 N/A** 2 (17%) 3 (30%) 2 (13%) 0 (0%) 3 (39%)
* Row % totals may equal more than 100% due to rounding. ** Case reports in the EMJ
were placed in separate sections from original articles starting in 1985, and were thus not
included in the overall text sample for this volume.
12
The term 'non-author-centred' is used here in preference to the term 'impersonal',
since the latter represents an inaccurate stereotype of modern scientific writing. In the
rhetoric of the modern EMJ, as in other scientific and science-based research writing,
authors are never entirely absent, although they may be 'submerged'. Thus, expressions of
'author's comment' (Adams Smith 1984), the strategic use of first-person pronouns
(Tarone, Dwyer, Gillette, and Icke 1981), politeness features (Myers 1989), and a variety
of author-indexing features are prominent in the scientific research report of the present
day. Brandt (1990) discusses further the interpersonal nature of so-called 'objective'
discourse.
13
For example, "The effects of a self-referral scheme on the pattern of hospital
admissions for acute asthma' and "Therapeutic drug monitoring—the need for audit?' are
two articles in the 1985 volume which are primarily concerned with hospital
management, yet have the experiment-based IMRD format.
14
The cases reported in this first category sometimes strike the modem reader as
nothing more than medical oddities. Thus, there are various descriptions of 'monstrous
births', for example, of children born with 'urinary and genital Organs preternaturally
formed', or 'to whose Neck was attached a Tumour nearly about the size of the child's
head'. Kronick (1976) notes the tendency of scientific journals from the century
preceding the establishment of the EMJ to publish such reports, and traces it back to an
earlier periodical tradition whose main purpose was entertainment.
15
The trend toward abstract presentation does not, however, signify that the original
type of case report—that based on a single disease event or condition—was completely
excluded from the EMJ after the nineteenth century. Rather, the single-case report
continued to exist over the years as a minor genre side-by-side with the more modern
types of medical research writing. It even appears that, by 1985, single-case reports are
making a modest comeback—for the first time in this corpus case reports are allotted their
own (albeit peripheral) section in the journal.
16
Table 1 also includes measures of statistical significance (F and p values) and

statistical importance (R-squared values) for each set of factor scores. P values indicate
whether the individual values in each group of factor scores (i.e. scores in each column of
Table 1) differ from one another at statistically significant levels; R-squared values
indicate how much of the variance among these scores is common, or co-variance. Biber
and Finegan (1989: n.9) give a particularly clear explanation of the meaning of these
measures.
17
The factor scores from 1945 and 1985 are based on 11 texts. This number resulted
from the fact that an alternative text was included in each of these periods' original text
samples (original N = 10), due to doubt on the researcher's part that one originally
chosen text in each sampling period actually qualified for inclusion in the sample.
Unfortunately, these texts were not then removed prior to factor analysis, and their
identities were subsequently confused, so that they could not be removed post hoc and
had instead to be left in the analysis. The total effect of having two questionable texts,
however, is thought to be minimal—since the texts were originally assigned to their
respective categories, they were at least rhetorically similar to the other texts in those
categories. Doubts about these texts were instead motivated by non-generic concerns—
the 1985 text which I had hoped to replace, for example, had a first author with a Chinese
family name, and, unlike other texts in this sample, several grammatical infelicities.
18
The features with high positive values on this factor are: past-tense verbs; third-
person pronouns; perfect aspect verbs; public verbs (for example, mention, promise, say,
and suggest); synthetic negation (i.e., no + quantifier, adjective, or noun; neither, nor);
and present participial clauses.
19
All features which loaded negatively on Factor 2 in Biber's (1988) general analysis
also loaded more saliently on other factors (see Biber 1988: chapter 5 for further details).
In order, therefore, to ensure the independence of each factor, such features were not
further considered as making up the factors on which they had these lower scores. This
sort of adjustment was also made on Factors 1 and 5. For this reason, no negative features
are reported on here for Factor 2.
20
By 'public', I do not mean that medicine became more accessible to the general lay
public. Rather, medical knowledge at this time became—to a much greater degree than
previously—a shared form of knowledge among a community or group of professionals.
Within that (progressively tightening) group, then, medicine became a public, rather than
an individual activity.
21
Recent research on narrative characterizes it as the mode of individual, particular-
istic expression (and thought) par excellence. According to Bruner (1986), for example:
application of the narrative mode leads... to good stories, gripping dramas, believable
(though not necessarily 'true') historical accounts. It deals in human or human-like
DWIGHT ATKINSON 367
intention and action and the vicissitudes and consequences that mark their course. It
strives to put its timeless miracles into the particulars of experience, and to locate the
experience in time and place. (1986:13)
APPENDIX
Example Texts from the Edinburgh Medical Journal
TEXT A: Narrative case report from 1735. 'A Tumor of the Nose unsuccessfully
extirpated by '
The author of Art. XII. in your first volume, having had the benefit of your promise to
conceal the names of those who send you unsuccessful cases, I claim the performance of

the same promise in the publication of this paper, if you think it deserves a place in your
collection.
A child was born with a small moveable tumor on its nose, which increased as the child
grew, otherwise the child was healthy and strong, having only had a short fever or two, and
passed some worms, beforefiveyears of age, when my advice wasfirstasked concerning
the tumor, which now was so large as to cover all the nose except the nostrils, and was so
prominent to each side, that the eyes were in part covered with it. Towards the base it was
so soft, that by pressing a finger on each side, they felt each other, but at the most
prominent part there were several hard round knots. When I saw it, the child complained
of no pain, though I was informed that sharp lancinating pains sometimes struck through
the tumor. I held the nostrils while the child forced its breath that way, but saw not the
tumor rise any. I searched into the nostrils with a probe, but could neither feel any
excrescence, nor push the tumor or teguments outwards. The Os frontis was firm, and
united in the middle. From all which I concluded the bones of the nose to be complete,
and therefore was of opinion the tumor (which would make the patient very miserable by
increasing, and would bring death at last) might be safely extirpated. Being however
taught by Job a Meekren (a), and some others, how deceitful excrescences of the head,
brought to the world with a child, might possibly be, I would not undertake the cure, till
another surgeon of more experience and longer standing in my neighbourhood, who
justly has a considerable character, should examine the tumor, and assist me in whatever
was determined to be done. That gentleman joining in opinion with me, I undertook the
extirpation with his assistance. When I had dissected about half the base of the tumor off, I
observed the bones of the nose to be incomplete, and that the membrane of the nose, part
of which I had laid bare, was moved outwards in expiration, and inwards in inspiration.
Not being certain how far upwards the bones might be wanting, I dissected the tumor off
at the lower part, but left a little of its base above. Having stopped the blooding, I dressed
the wound in the common way.
When the tumor was examined, it appeared all of a substance a little firmer than the
common fat under the skin, except where the knots were, which were of a schirrous
hardness.
The child passed thefirstnight pretty easily. Next morning the pulse was a little quick,
attended with a thirst, and a sickness at the stomach, which had made the patient vomit
once. An emollient clyster being injected and emulsion given for drink, these symptoms
abated. Towards the evening the dressing seemed moister than they commonly are soon
after a wound.
In the morning of the second day after the operation, the dressings, child's hair and
head-clothes, and the pillow under its head, were all wet with a watery liquor, which had a
particular smell that I never felt in any wound before, and do not know how to describe.
The dressings being taken off, we saw that this liquor oozed fast from the bared
membrane of the nose, though we could not perceive the orifice by which it escaped. We
applied for time to time, bol. Armen, Pulv, Helvet, Chalk, Sugar of Lead, white Vitriol,
burnt Allum, blue vitriol, quick-lime, Brandy, alcohol, Oil of Turpentine, Spirit of Nitre
dulcified, plain Spirit of Nitre, Oil of Vitriol, Lunar Caustic, the actual Cautery. In short,
we applied everything we could think of that had any chance of stopping this oozing of
lymph, but without success. On the sixth day our patient vomited a long round worm; in
some time after fell into convulsions, and in an hour more died.
TEXT B: Case report following narrative schema from 1775. 'The History of a fractured
Sternum.' By Mr George Borthwick, Surgeon to the 14th Regiment of Dragoons

One of the men belonging to the 14th regiment had his breast violently squeezed against a
manger, by a vicious horse which he was dressing in the stable. When I saw him, which was
about ten minutes after the accident, he complained of violent pain in the breast, which
extended to each side, and of a difficulty in breathing. On examining the sternum, I found
it fractured transversely, immediately above the joining of the cartilages of the fourth ribs.
A grating noise was distinctly heard at the fracture, both at the time of inspiration and
expiration; and the solution of continuity was still more evident on handling it; at the same
time, the extremity of the one fragment did not rise above the other.
Having found what I have now mentioned to be the case, I immediately took twelve
ounces of blood from his arm, had him carefully conveyed to bed, when I applied a broad
flannel roller around the thorax, and a compress of the same substance on the course of
the sternum, under the roller, which was made to go but once round the body, that I might
the more conveniently and safely unbind it afterwards when necessary. The bandage was
not applied so tight as to affect respiration, but was intended merely to preserve a general
steadiness in the parts, which it certainly did, as the grating noise in the fracture was not to
be heard from the time of its application.
The first night after the accident he rested very ill, and when I saw him in the morning I
found he had contracted a cough, which, though slight, occasioned violent pain in the
whole chest, and at the fracture. This symptom soon yielded a second bleeding, and some
mild diaphoretics. From the third day after the accident, he continued to do well until the
9th day, when he became comatose, and remained stupid for fifteen hours, after which he
perfectly recovered his sense, perhaps owing to sinapisms which I applied to his feet. He
now complained of a numbness in the right-side, which was so great, that the skin was
insensible to the puncture of a needle. After this he continued to recover daily, and was
perfectly well in the space of seven weeks. The numbness in his side continued more than
two months, but went entirely off. During the whole of his illness, the pain from the
fracture, and difficulty of breathing, were much less than might have been expected.
TEXT C: Case report showing three-part content organization from 1820. 'Case of an
Unusual Termination of Phthisis Pulmonalis, by a Sudden and Fatal Hemorrhage from
the Lungs.' By S. G. Lawrance, Member of the Royal College of Surgeons, London, and
Assistant Surgeon to the Military Asylum, Southampton.
C R , aged 19, a delicate female, was suddenly attacked with a spitting of blood, while
walking, on the 26th December 1817, and five or six ounces of blood were expectorated.
It recurred on the 27th, when nearly an equal quantity was lost. She has had a cough, with
occasional pain in the chest, for some time, but until now, had had no medical advice. She
had always menstruated very irregularly.
DWIGHT ATKINSON 369
Venesection and the usual antiphlogistic mode of treatment were employed. The
haemorrhage did not return, but the cough continued until the beginning of February
1818, when it entirely left her, and, though much debilitated, her appetite returned, and
she appeared to be perfectly recovered.
She remained well until the beginning of April, when she caught a severe cold, and the
cough then returned, with copious expectoration, occasionally streaked with blood, and
continued, in spite of every mode of treatment. The expectoration at length became
purulent, attended with the usual symptoms of phthisis, with hectic fever, profuse night-
sweats, &c. Digitalis was given with benefit, appeasing the cough, which was the most
troublesome symptom, and lessening the frequency of the pulse; but yet with no
permanent benefit, for when discontinued on account of its producing slight vertigo and
an intermitting pulse, in a short time the cough returned as before, the pulse varying from

80 to 100.
Tar vapour, as lately recommended by Sir Alexander Crichton, was also tried, but the
cough was not mitigated, nor did any benefit appear to result from its use. Being originally
thin and delicate, she soon became greatly reduced and emaciated, and the phthisical
symptoms rapidly increased. On the 9th of September, during a violent fit of coughing,
she suddenly spit up two large masses of coagulated blood, of a very firm consistence,
resembling pieces of liver; their upper surface were covered with frothy mucus, and had a
cellular appearance. The largest mass weighed upwards of an ounce and a quarter, of
which a rough sketch is annexed; the lesser, three quarters of an ounce. This was followed
by an immediate and profuse hemorrhage, and she instantly expired.
Examination of the Body
Thorax. The lungs on both sides of the chest adhered veryfirmlyto the costal pleura, and
their investing pleura was much thickened. The right lung was tuberculated, and had a few
small vomicae in it. The left was much more diseased, being full of tubercles, and small
abscesses, and at the upper and back part of this lung there was a large cavity, containing
only frothy blood and mucus; in this, no doubt, the large coagulum had been contained, as
the cavity corresponded in point of size.
The pericardium was thicker than natural, and contained about §i of serum.
. The heart was small, flaccid, of a pale colour and contained very little blood in its
cavities. There was no extravasation of blood or other fluid in the thorax.
Abdomen. The liver was much larger than natural, extending quite across the
abdomen, so as to cover the stomach, to which it was connected by thread-like bands, and
its upper surfacefirmlyadhered to the peritoneum, and to the diaphragm. The stomach,
spleen, and rest of the abdominal viscera, shewed no marks of disease.
Remarks. The dissection proves this to have been a case of phthisis pulmonalis, and its
unusual termination was the more extraordinary and unexpected, as there had been no
recurrence of hemorrhage from the 27th December 1817, until after her death. For the
last two months I daily observed the expectorated matter, and it was scarcely ever even
streaked with blood. The time, therefore, when the blood, which formed the coagula, was
first effused into the lung, is uncertain, but that they acted as plugs to the mouths of the
pulmonary vessels which had been ruptured is evident, and that they performed this
office for some considerable length of time, is, I think, proved by what I have stated above,
as well as by the veryfirmand solid texture, and general appearance of the coagula.
Southampton, Oct. 5,1818.
TEXT D: Large-case disease review from 1985. 'Chronic Subdural Haematoma in the
CT Scan Era.' F. Nath, A. D. Mendelow, C.-C. Wu, Cathy Hessett, F. Caird, and B. Jennet
Summary
One hundred and fifty patients with chronic subdural haematoma were studied with
respect to clinical features, investigation and outcome. Those patients aged 65 years or
over did not differ significantly in either outcome or clinical features from the rest. The
outcome in this series of patients, managed after CT scanning became the standard
method of investigation, was no better than in previous studies. The only factor which did
influence outcome was the level of responsiveness on admission. The overall mortality in
this study was 6 per cent. CT scanning does not therefore result in improved results in
patients with chronic subdural haematoma; this may rather depend upon better selection

of patients for CT scanning.
Keywords: CT scan, chronic subdural haematoma. Chronic subdural haematoma
(CSDH) is a well-recognized cause of mental impairment and headache, especially in the
elderly. Because the result of evacuation by the simple procedure of burr holes is usually
so satisfactory clinicians should ensure that this diagnosis is not missed, but is made soon
enough to obtain a good result from surgery. It was natural that once CT scanning became
available there would be discussion about its place in the diagnosis of CSDH. In particular
the question arose whether large numbers of elderly demented patients should undergo
CT scanning in order to discern cases of intracranial haemorrhage.
The most recent large series of cases of CSDH reported included very few who had
been scanned and we report now a series of similar size collected since CT scanning
became available. We make comparison between these two series, and also between
younger and older patients with this condition.
Methods
Between 1974 and 1980, 150 patients underwent surgery for chronic subdural
haematoma at the Institute of Neurological Sciences in Glasgow. Chronic subdural
haematoma was defined as a subdural collection of dark fluid. One hundred and thirty
patients were admitted to the neurosurgical unit and 20 were initially referred to the
University Department of Geriatric medicine and later transferred to the neurosurgical
unit. Ninety-six patients were derived from the Scottish Head Injury Management Study.
Thirty-four were extracted from case records after being identified by their operative
records and analysed by medically qualified personnel.
The clinical features noted were headache, vomiting, pupillary reactions,fitsand focal
neurological signs. Conscious level was assessed at the time of admission by the Glasgow
Coma Scale (GCS). Outcome was assessed at three months by the Glasgow Outcome
Scale; death, persistent vegetative state or severe disability were regarded as a poor
outcome, while moderate disability or good recovery were classified as a good outcome.
Figures were set out in contingency tables and statistical analysis was performed with the
chi-squared test using Yates' correction. A difference was regarded as significant when
P<0.05.
Results
Of the 150 patients studied, 48 per cent were aged 65 years and over, while only 5 per
cent aged 15 years or under. The clinical features in two groups (under 65 years and 65
years or over) are summarized in Table I. Symptoms or signs of raised intracranial
pressure occured as commonly in the two groups. Headache occurred in 27 per cent of
those aged less than 65 years and in 23 per cent of the older group. Vomiting occurred
DWIGHT ATKINSON 371
with almost equal frequency in the two age groups. Pupillary inequality was seen in 19 per
cent of the younger group and 12 per cent of the older patients. The most common focal
neurological sign was motor limb asymmetry in 52 per cent; 48 per cent in those under 65
years and 57 per cent in those over 65 years. Dysphasia was noted in one fifth of the
patients with an equal incidence in the two age groups, and cranial nerve abnormalities
were seen in 10 per cent of the younger and 15 per cent of the older group. Fits were twice
as common in the younger group at 11 per cent, compared to 5 per cent of the older
patients. There were no significant differences in the occurrence of any individual clinical
features beween the two age groups.
Twenty per cent of our patients were in coma on admission, with no eye opening or
speech (GCS score 3-9). Of the remainder, 63 per cent were either fully conscious or
confused with or without eye opening to speech (GCS score 13-15) (Table II).

Investigation. A clear history of trauma was seldom elicited but a skull fracture was
demonstrated in 25 per cent of the 39 patients who had a skull x-ray. The majority of our
patients underwent CT scan (87%). Carotid angiography was only performed in 19 per
cent; isotope brain scan in 14 per cent and lumbar puncture in 3 per cent.
Treatment. The surgical treatment in 91 per cent of our series was burr hole drainage with
saline irrigation of the subdural space. Craniotomy was only necessary in 6 per cent and
craniectomy in 3 per cent.
Outcome. The outcome was regarded as good (good recovery or moderate disability on
the Glasgow Outcome Scale) in 89 per cent of patients (Table HI). Included in this
outcome group are twenty elderly patients. Although some of them had pre-existing
dementia or cerebrovascular disease they were all rendered asymptomatic or returned to
their former state of health, and have thus been included in the 'good outcome' group.
There was no statistically significant difference in outcome between the two age groups
(Fig. I). There was also no significant difference in the percentage with a good outcome
between those who had CT scan and those who did not (Fig. I).
Of the patients in coma (GCS <9), 30 per cent had a poor outcome, while in those with
a coma score of 10 or greater only 7 per cent had a poor outcome (Table IV). The overall
mortality in this study was 6 per cent.
Discussion
The most common clinical features in our patients were headache, dysphasia, hemi-
paresis and confusion with a depressed conscious level. There was no predominance of
any particular clinical feature in the older patients. Although increasing age is associated
with a poorer outcome in acute head injury, it did not affect outcome adversely in patients
with CSDH in our study. The generally slow evolution of the clinical picture accounts for
its frequent misdiagnosis as dementia, tumour or ischaemic stroke. This further
emphasises that the diagnosis of CSDH should be considered in patients of all ages when
raised intracranial pressure or supratentorial neurological signs are present.
The mortality in this series is similar to that reported by Cameron (4%) and indeed
shows little change from that of McKissock et al. (10%). Higher mortality figures have
been reported, although these were from smaller series: e.g. Tabbador et al. (21%); Plum
and Posner (19%). The absence of a marked change in mortality suggests that the advent
of CT scanning as a non-invasive technique has had little effect on mortality in patients
with CSDH. This is in contrast to intracerebral haemorrhage but in keeping with current
thinking on acute head injury.
Eighty-seven per cent of our patients underwent CT scanning; a much higher
proportion than in any earlier series. Because our mortality (6%) is only slightly lower
than that reported by McKissock et al. years ago (10%) and is actually marginally higher
than Cameron'sfigure(4%) which was achieved with only 3 per cent of the patients being
scanned, we would suggest that although CT scanning is a safe non-invasive technique,
any further reduction in mortality in CSDH could only be achieved by a change in
management policy which would lead to earlier referral and an earlier CT scan. This has
been clearly documented in patients with acute head injury and it may also apply to
patients with CSDH. It may therefore be the way that the CT scanner is used rather than
its routine use in unselected patients that would lead to improved results.
The results of treatment in patients over 65 years did not differ when compared to the
results in younger patients in this study. There is therefore every reason to actively

investigate and treat elderly patients with symptoms or signs indicative of chronic
subdural haematoma.
Although CT scanning is safe, fast and reliable, the presence of an isodense subdural
collection may make interpretation difficult in some cases. However, the diagnosis of a
chronic subdural haematoma was made correctly in all patients who had a CT scan in this
study. In practice it would not be possible to scan all patients in the United Kingdom with
a history suggestive of chronic subdural haematoma because of the limited availability of
CT scanners. This was emphasised in a recent study which showed that there was a very
low yield of patients with chronic subdural haematoma if all patients with dementia were
routinely scanned.
Previous studies have shown that isotope brain scanning is accurate in 93 per cent of
cases. This figure may be even greater in the elderly since the thickness of CSDH
increases with advancing age. CT scanning should therefore be the ultimate confirmatory
examination where other more readily available screening tests such as the isotope brain
scan have suggested the diagnosis of chronic subdural haematoma.
Conclusion
1. There has been no demonstrable change in mortality for patients with chronic
subdural haematoma since the introduction of CT scanning.
2. The outcome from surgery and the clinical presentations in the elderly did not differ
significantly from those in younger patients.
3. Better results of treatment of chronic subdural haematoma may not be dependent on
the use of the CT scan; rather they may depend upon earlier screening, referral and
treatment of patients at risk.
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The Evolution of Medical Research Writing

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The Evolution of Medical Research Writing from

1735 to 1985: The Case of the Edinburgh

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of written scientific discourse, it tends to have several limitations. The selective

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2. DEVELOPMENT AND MODERN FORM OF THE SCIENTIFIC RESEARCH ARTICLE

descriptions of experiments. Shapin shows how such descriptions were a crucial

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Regarding attention to the second point mentioned above—organizational

According to Dear, the persuasive power of accounts like Boyle's depended

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1 Scientific research articles, far from being straightforward accounts of

Results/Discussion (IMRD) structure is in one sense an attempt to provide

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4. RESEARCH SUBJECT: THE EDINBURGH MEDICAL JOURNAL

regularly for much of the eighteenth century—during part of which it was

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of 'facts' or 'conventions for construing reality' (Bizzell 1982), which

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Informational Narrative Explicit Overt Abstract

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6.1 Rhetorical level: Content and formal organization of original articles

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followed by a post-mortem description, followed by a discussion of the case.

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6.2 Rhetorical form and content of the case report

(1) GENERAL PATIENT INFORMATION (+ COMPLAINT STATEMENT):

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(6) SUBSEQUENT COURSE OF ILLNESS/CONDITION - often given in short or

conventionalized 'content structure' (Meyer 1975) is diagrammed in figure 3

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6.3 Linguistic level: Overall results of diachronic register analysis of original

Date N Factor 1 Factor 2 Factor 3 Factor 4 Factor 5

1735 10 6.43 3.15 1.02 -0.77 4.40

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indicating an informational vs. involved production textual dimension—with

scores, while such features as contractions, second-person pronouns, post-

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Factor 3, on which three types of relative clauses, phrasal coordination, and

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The fourth factor, designated overt expression ofpersuasion by Biber (1988),

Overt Expression of Persuasion

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6.4 Diachronic register variation in the case report

Date N Factor 1 Factor 2 Factor 3 Factor 4 Factor 5

1735 4 6.03 6.45 2.16 -3.17 3.35

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Factor 3—explicit vs. situation-dependent reference—is difficult to interpret in

developmental trend with representative text samples from 'Remarks' sections

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nineteenth century. The particular tenacity of this form of discourse in the

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community. By the early-to-mid-nineteenth century significant long-term

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Texts in this period fully reflect the new-found possibility of case-based

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Date Case Disease Treatment Experiment Speech Other