Richard Smith: Case reports in 16th century Europe and China

Richard SmithThere is a huge theoretical body of knowledge about the history of the novel, but almost nothing on the history of the medical case report. Gianna Pomata from Johns Hopkins University would like to change that and is writing a book on the history of the medical case report. Last week she gave a talk on the near simultaneous appearance of medical case reports in 16th century Europe and China as part of a workshop on “Medical case histories as genre,” organised by the King’s College Centre for the Humanities and Health.

I was there, but I must begin my attempt at a blog on some of what I learnt with an apology—as I had trouble adapting to the humanities way of communicating. The tradition is that the scholars read papers for about 45 minutes and then there is a discussion. The papers are dense and written in language that I struggle to follow. Here’s an example: “On the grounds that medical cases merely lend themselves to the confirmation of abnormalities, and not to the modification of norms, Foucault severed the medical from the legal case, and cut short the discussion of the mutually constitutive reciprocities of individual case and recognised categories.” I do at least know who Foucault is (see below), but I couldn’t keep this up all day and so left at lunchtime. But I liked what I could understand.

The case report is the quintessential interaction between literature and medicine, said Monika Class from King’s, who organised the meeting, but case reports are also common in ethics, the law, and theology. Case reports are thus potentially rich territory for the medical humanities, but the French philosopher, Michel Foucault, rather dampened enthusiasm by suggesting that a case report turns patients into objects and is ultimately a form of repression. An aim of the meeting seemed to be to present a much more positive view of medical case reports.

Case reports, said Pomata, are one of the basic forms of narrative, with other forms including myths, sagas, legends, jokes, recipes, and fairy stories. She likes to call them an “epistemic genre,” a form of knowledge that allows doctors to share learning and increase knowledge. One Chinese definition of case reports is “written traces left by the physician in the search of knowledge.” A phrase that recurred during the meeting was “thinking in cases,” a way, I’m sure, that many doctors think.

The core of Pomata’s talk was to compare the first collections of case reports from Europe and China. The first collection from Europe came from the Portuguese Jewish physician Amatus Lusitanus, who published 700 cases in instalments of 100 each from 1551-1556. The first from China were the Stone Mountain Medical Case Histories of Wang Ji written up and published in 1531 by his disciple Chen Hue. There were about 100 case histories gathered over 15 years.

Like others in the workshop I wondered why Pomata had dismissed Hippocrates’s Epidemics, which contain some 300 case histories. She said books one and three, the ones that are certainly by Hippocrates, do not include anything on treatment, but only on the natural history of disease. Then even the books that do contain information on treatment are thin case reports, “like an embryo,” she said.

The early European and China case reports have a very similar format, with some being collections by single authors and others anthologies with multiple authors. Johannes Schenck von Grafenberg in 1584-97 in Europe and Jian Quan in 1549 (published in 1591) in China both provided instruction on how to write case reports, and collections of case reports grew quickly.

The main functions of the collections of case reports were learning and marketing. Teachers had taught their apprentices with oral descriptions of cases, but by writing them down and printing them they could reach larger audiences. The collections of case reports, which were often compiled by students of the masters, were also a way of promoting the doctors. The doctors compiling the collections were mostly elite doctors treating elite patients.

In both Europe and China medical case reports evolved in parallel with legal case reports, and the emphasis was very much on individual diagnoses and treatments. Each patient needed individual attention, and “one size fits all” was thought to be the mark of a charlatan. (I reflected with her that psychoanalysts have stuck with this idea, explaining, they say, why it’s impossible to test their treatments in randomised trials.)

A difference between Europe and China was that those from Europe emphasised experience, whereas those from China often blurred experience and the standard theory on medicine. As Pomata put it, China reports were “defenders of the text,” whereas those from Europe were “defenders from the text.” These differences reflected different cultural traditions with Europeans valuing debate and argument and the Chinese respecting authorities. (I see these differences teaching around the world: in Europe the students will tell me why I’m wrong, while in China the students expect me to deliver wisdom without asking them to participate.)

In China the doctors thought of the case reports as being for patients as well as other doctors and part of the treatment. Still today, Pomata said, if you visit practitioners of traditional Chinese medicine they will give you a blank book in which they will write down your case history.

Another difference was illustrated by an account of the British doctor, Hugh Gillan’s experience with a senior official in China in 1792. He examined him, and the official was amazed, firstly, that the Gillan asked him many questions about his history, and, secondly, that he wasn’t much interested in his pulse. The Chinese doctors put huge emphasis on the pulse as the main way of making a diagnosis.

Pomata ended by wondering whether the similarities between the European and Chinese case reports had arisen because of contact between the two cultures. There was interaction between the cultures, with exchanges in astronomy and medical knowledge, including of anatomy and recipes for treatments. But she has so far found no evidence of exchange of case reports.

So case reports close to those we know now were born in the 16th century, grew in importance, and then rather faded in the late 20th century. They do now, however, seem to be resurging, perhaps as interest in personalised medicine grows.

The enthusiasm at the workshop and the fact that it has to be moved to a larger room perhaps means that Pomata will see the emergence of theoretical base in the study of the history of case reports.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.