In the 1850s, a physician at St. Bartholomew Hospital in London struggling with an unclear case of fever with affection of the bowels might have wanted to find information about the patient’s prognosis or an alternative medical treatment. Likewise, a medical student preparing a case for presentation to the hospital society, might have wanted further information about typhus fever, namely, its course, average prognosis, possible complications, and treatment. Both doctor and student would probably visit the library of the hospital’s “Medical College” to find comparable cases and case reports in voluminous bound casebooks.
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By the twentieth century, handbooks had become heavy doorstops. Aspiring to encyclopedic knowledge about a scientific field, they often comprised multiple tomes like the ten-volume third edition of the German handbook on pathogenic microorganisms, whose volumes also had subvolumes). By contrast, I will present a kind of hybrid handbook, something between a casebook and a handbook, a handbook that was literally a manual: manually written and used to ensure that knowledge was at hand. The books, bound and labelled “Medical Notes” or “Reports of Cases,” each contained a collection of typical or standard case histories based on practical experience for use as a reference.
As part of my project on “accounting” (in a broader sense of calculative practices) and “bookkeeping” (in the broader sense of keeping the books) in medicine, I am examining casebooks and compilations of case reports. Drawing on the work about paper knowledge and technology by Cornelia Vismann, Anke te Heesen, Lisa Gitelman, Volker Hess, and Andrew Mendelsohn, I analyze how these books were produced, for what purpose they were used, and how medical practice on the ward became medical knowledge through the documenting of cases. But beyond medical knowledge about an individual patient’s illness or about diseases in general, my main focus is on the infrastructure of knowledge production in scientific institutions, in particular on a kind of organizational knowledge or know-how involving institutional processes, administrative techniques, as well as calculative and economic practices.
Where did case collections come from and what purposes did they serve? Originally and, the patient’s history was recorded, in chronological order, in so-called casebooks as part of the daily routine on the hospital ward. The practice of recording detailed case histories arose in the second half of the eighteenth century, becoming an implicit part of the medical school’s curriculum from the 1770s. Especially in recent years, many studies have been published on the epistemological role of case histories and their importance in the production of medical knowledge. According to these studies, cases, case histories, and case records were a prominent source of nineteenth- and twentieth-century medical knowledge.
Casebooks were attached to specific wards. As an “Outline for Case-Taking” emphasized,
HISTORIES ARE NEVER TO BE TAKEN FROM THE WARD.
Because cases were recorded in chronological order (and later on because they were kept for every ward), it was difficult to find cases of a specific disease. Eventually, the cases were listed in a “Table of content” by the hospital’s medical registrar William Senhouse Kirkes (1822–1864) and likely became part of the medical library’s holdings:
[Case] xxi 93 Apoplexy.
[Case] xxii [page] 95 Hemoplegia …
[Case] xxiii [page] 105 Chorea. Fatal.
[Case] xxiv [page] 109 Spinal Irritation.
[Case] xxv [page] 113 Paraplegia. Softening of spinal cord.
To ensure a more systematic collection of cases, some histories were transcribed. Ward physicians or house surgeons like William Peirs Ormerod (1818–1860) copied by hand those cases considered typical, or, to quote the clinical clerk at St. Bartholomew Hospital John Edward Gross, “those cases which are of common occurrence; with which one is more intimately concerned in future life” as a physician. The compiler may well have added further information, classified the cases, and arranged them in systematic order, for instance according to the nature of the disease, and produced a “General Index” that differentiated between:
16 Rheumatic Fever. Endocarditis and Pericarditis. Recovery …
17 Rheumatic Fever. Endocarditis. Recovery …
19 Chronic Rheumatism—2nd attack. Recovery …
20 Chronic Rheumatism—9 months duration. Endocarditis …
Depending on the purpose of the compilation, the “book” production was an on-going process. Every day of the year, blank ledgers were filled with written reports about cases treated on the hospital wards. In addition, in the 1840s, Omerod systematically transcribed cases in a separate ledger in accordance to his surgical needs, while later on further cases were added, inserted between the categories, and pasted between the pages. This bricolage allowed for the comparison of similar cases and, if a new case history differed from ongoing patterns, one could complete the collection.
Whereas Omerod compiled his “handbook” over a period of ten years, Gross selected cases he had taken as a clinical clerk on the medical wards over a period of six months. As part of becoming a physician, Gross intended to compile commonplace cases by hand, from and for his daily work (or later on for the library’s inventory) in order to be able to look up similar cases and evaluate or compare symptoms and courses of diseases with current cases.
Guided by slightly different aims, assistant physicians and surgeons browsed through the casebooks, or medical registrars like Kirkes, once a table of contents had been produced, and they selected cases that seemed appropriate for clinical demonstrations and teaching. At some point, the compilations and casebooks were inventoried in the hospital’s medical school library. With the aid of a table of contents or a general index, physicians, surgeons, clinical clerks, and students could then use them to look up information on former case histories. In one way or another, then, casebooks and compilations like those of Ormerod and Gross not only documented a patient‘s case history but were used like printed handbooks or manuals.
Filling blank ledgers with case histories, producing registers and indices, and compiling case reports all produced medical knowledge in various ways. Certainly knowledge was produced about the disease of an individual patient. Indeed, rare and special cases collected in the casebooks were sometimes published and discussed in medical journals. But beyond case knowledge, the compilers and medical registrars produced medical knowledge by re-arranging the cases, bringing them into a new order, and by describing and comparing cases with typical symptoms, characteristics, and courses of diseases. Cases that seemed to be of broader interest were also published in journals. In addition, some editors of these hand-assembled case handbooks published manuals and textbooks. I suppose that these case handbooks could have been either some sort of groundwork for a publishing project or that the idea of publishing a manual originated from making these case handbooks in the first place. Finally, the casebooks were also used to train and educate medical students in the art of medicine, not to mention in case-taking and medical bookkeeping.
Axel C. Hüntelmann is a research fellow at the Institute for the History and Ethics of Medicine, Charité—Universitätsmedizin Berlin.
- See Wilhelm Kolle et al., eds., Handbuch der pathogenen Mikroorganismen. 3rd. ed. (mit Einschluß der Immunitätslehre und Epidemiologie sowie der mikrobiologischen Diagnostik und Technik) 10 Vols. Jena: Gustav Fischer 1928–1931. ↩︎
- Cornelia Vismann, Files. Law and Media Technology (Stanford, CA: Stanford University Press, 2008; Anke te Heesen, “Accounting for the Natural World: Double-Entry Bookkeeping in the Field,” in Colonial Botany: Science, Commerce and Politics in the Early Modern World, ed. Londa Schiebinger and Claudia Swan (Philadelphia, PA: University of Philadelphia Press 2005), 237–51; Volker Hess and J. Andrew Mendelsohn, “Paper Technology und Wissensgeschichte,” NTM Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin 21, 1 (2013): 1–10; and Lisa Gitelman, Paper Knowledge: Toward a Media History of Documents (Durham, NC: Duke University Press, 2014). ↩︎
- See Guenter B. Risse, Hospital life in Enlightenment Scotland. Care and Teaching at the Royal Infirmary of Edinburgh (Cambridge, UK: Cambridge University Press, 1986). ↩︎
- See, for example, John Forrester, “If p, then what? Thinking in Cases,” History of the Human Sciences 9, no. 3 (1996): 1–25; Gianna Pomata, “The Medical Case Narrative: Distant Reading of an Epistemic Genre, Literature and Medicine 32 (2014): 1–23; Susanne Düwell and Nicolas Pethes, eds., Fall, Fallgeschichte, Fallstudie: Theorie und Geschichte einer Wissensform (Frankfurt am Main: Campus 2014); Jörg R. Bergmann, Ulrich Dausendschön-Gay, and Frank Oberzaucher, eds., “Der Fall”: Studien zur epistemischen Praxis professionellen Handelns (Bielefeld: Transcript, 2014). In general, historiography on cases in medicine has been limited to three aspects: the epistemic aspects of cases in the context of knowledge production; cases as a genre in literature, e.g., Yvonne Wübben and Carsten Zelle, eds., Krankheit schreiben: Aufzeichnungsverfahren in Medizin und Literatur (Göttingen: Wallstein, 2013); and cases in psychiatry, e.g., Cornelius Borck and Armin Schäfer, eds., Das psychiatrische Aufschreibesystem (Paderborn: Wilhelm Fink 2015). ↩︎
- George Dock, Outlines for Case Taking and Routine Ward and Laboratory Work as used in the Medical Clinic of the Washington University. 2nd ed. (Ann Arbor, MI: George Wahr 1913), 4. ↩︎
- William Senhouse Kirkes, Registry of Medical and Surgical Cases, Reported from October 1848 to April 1849, Volume I, Table of Contents, Archive of St. Bartholomew Hospital (SBHB), Medical Records (MR) 16/8. ↩︎
- John Edward Gross, Introductory Remarks, in: Reports of Cases taken in the Medical Wards of St. Bartholomew’s Hospital, from September 1855 to April 1856, in, Archive of St. Bartholomew Hospital, Personal Papers (SBHPP), JGR.1 (John Gross). ↩︎
- John Edward Gross, General Index, in: Reports of Cases taken in the Medical Wards of St. Bartholomew’s Hospital, from September 1855 to April 1856, in, Archive of St. Bartholomew Hospital, Personal Papers (SBHPP), JGR.1 (John Gross). ↩︎
- See Keir Waddington, Medical Education at St. Bartholomew’s Hospital 1123–1995 (Woodbridge: Boydell Press 2003), 106. ↩︎