Case Studies and the Dissemination of Knowledge

Joy Damousi,Birgit Lang,Katie Sutton

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317599333
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

The case study has proved of enduring interest to all Western societies, particularly in relation to questions of subjectivity and the sexed self. This volume interrogates how case studies have been used by doctors, lawyers, psychoanalysts, and writers to communicate their findings both within the specialist circles of their academic disciplines, and beyond, to wider publics. At the same time, it questions how case studies have been taken up by a range of audiences to refute and dispute academic knowledge. As such, this book engages with case studies as sites of interdisciplinary negotiation, transnational exchange and influence, exploring the effects of forces such as war, migration, and internationalization.

Case Studies and the Dissemination of Knowledge challenges the limits of disciplinary-based research in the humanities. The cases examined serve as a means of passage between disciplines, genres, and publics, from law to psychoanalysis, and from auto/biography to modernist fiction. Its chapters scrutinize the case study in order to sharpen understanding of the genre's dynamic role in the construction and dissemination of knowledge within and across disciplinary, temporal, and national boundaries. In doing so, they position the case at the center of cultural and social understandings of the emergence of modern subjectivities.

I Case Knowledge

1 The Case of the Archive

Warwick Anderson

DOI: 10.4324/9781315746777-2

As medical students during the late 1970s, we routinely searched the hospital wards for cases, for the “good cases” of some particular disease. By early morning, rumors spread about which cases had come in overnight, and their disposition. We clustered around the good cases, trying to avoid the bad and routine ones. Even around 1980 our clinical teachers were insisting we should not regard patients simply as cases of whatever it is that afflicts them, as medical or administrative objects. But we continued to do so; indeed, the creeping sense of misconduct just seemed to make more tantalizing our quest for the case. We wanted exemplary cases of some disease, not sick people. It made us feel like grown-up doctors, whatever our instructors might say.¹ But what makes someone a case? How does one authorize a case? Does the case boast a genealogy? What are the consequences of becoming a case, or making cases? These are not the questions that medical students ordinarily ask, but they began to trouble me as I drifted away from the profession.

This chapter primarily concerns the case file, the administrative dossier, not the long case study, which is a distinct modernist genre—though the two are not unrelated. Michel Foucault connected the emergence of clinical sciences toward the end of the eighteenth century with the “problem of the entry of the individual (and no longer the species) into the field of knowledge; the problem of the entry of the individual description, of the cross-examination, of anamnesis, of the ‘file’ into the general functioning of scientific discourse.” In closed institutions like prisons, asylums, barracks, schools, and hospitals, “the examination, surrounded by all its documentary techniques, makes each individual a ‘case’: a case which at one and the same time constitutes an object for a branch of knowledge and a hold for a branch of power.” The case becomes the “individual as he may be described, judged, measured, compared with others, in his very individuality; and it is also the individual who has to be trained or corrected, classified, normalized, excluded, etc.”² Here I want to focus on one of these documentary techniques: the development of the hospital case file and its archive in the early twentieth century, more than one hundred years after the clinical sciences, according to Foucault, began making cases. For the first time, a unitary dossier necessarily accompanied patients along their “illness trajectories,” circulating with them through the modern clinics, waiting in the hospital records department for their return, available to turn them again into serviceable individuals within the bureaucratic matrix.³

Despite Foucault's discovery of the disciplined individual in the clinical case, we still know remarkably little about the documentary techniques that came to stabilize this identity. The bureaucratic entailments of making a diagnosis, fixing someone as a case, remain frustratingly obscure.⁴ We know that during the nineteenth century the medical record assumed a more standard form, almost ritualized, with more emphasis on “objective” physical examination and laboratory results, and a tendency to discount the patient's own impressions of the illness. Mostly, these accounts consisted of brief notes, accumulating piecemeal in casebooks and bundles, usually arranged chronologically, but sometimes according to diagnostic category. Not until the early twentieth century were the patient's records commonly collated in a unitary file, organizing and consolidating the ordinary concatenation of medical events and interventions into an individual life.⁵ The hospital record then comes to resemble the dossier, yet another example of the bureaucratic mode that produced during this period the police file, the military record and service number, and the anthropometric data card in physical anthropology. In the unitary administrative file, the individual case finally takes form in serial order, accompanied by rules of accessibility.

CASE STUDIES

The bureaucratic case file, which usually required secrecy, should be distinguished from the contemporary genre of the case study, which demanded full disclosure. Lauren Berlant wryly observes, “case history tends to be what physicians take, while case study is what academics and psychoanalysts write.”⁶ At the beginning of the twentieth century, Sigmund Freud wrote five long case studies that served as exemplars of psychoanalytic technique and literary style: “Dora” (1905), the “Rat Man” (1909), “Little Hans” (1909), Daniel Paul Schreber (1911), and the “Wolf Man” (1918). These narratives artfully described in each case a continuity of experience, suturing together apparent disjuncture, eventually revealing the hidden cause of the individual's distress. Unlike hospital case files, these studies emphasized the interaction of patient and analyst, dramatizing the transference implicated in the clinical encounter, thereby providing examples of how to perform psychoanalysis. Freud makes himself self-consciously present in his narratives in ways forbidden to ordinary physicians in their hospital case notes.⁷ Indeed, these ideographic case studies convey the impression of resisting, perhaps even subverting, the bureaucratically serviceable, and hence nomothetic, case file. Thus Freud's strategy of avoidance and denial parallels the concurrent rise of photographic modernism in opposition to the Bertillon system of photographic realism, then a common means of criminal identification.⁸

“It still strikes me myself as strange,” Freud observed as early as 1895, “that the case histories I write should read like short stories and that, one might say, they lack the serious stamp of science.”⁹ In the study of the Wolf Man, his last major case, Freud proclaimed: “I am unable to give either a purely historical or a purely thematic account of my patient's story; I can write a history neither of the treatment nor of the illness.”¹⁰ Instead, he wrote a modernist short story in which the author became the central character. At least since the 1960s, Freud's case studies usually have been taken as evidence of his literary bent, not read as scientific reports.¹¹ To be sure, historians have traced the genealogy of the Freudian case study—its family romance, perhaps—and noted legal, philosophical, and clinical antecedents to reasoning in cases.¹² But the Freudian literary style obviously is distinct from the bureaucratic dossier, which gained form about the same time. Although sharing a focus on the case, they boast different functionality. Still, their potential relations are intriguing. How, one wants to know, did Freud organize his own case notes? In the Freud archive there are numerous patient files from his days at the Allgemeines Krankenhaus, Vienna (1881–1883), and from the Bellevue Sanatorium, Kreuzlingen, in the early twentieth century.¹³ Those from the 1880s seem to have been bound together in a larger journal or case book, while the later ones are bound individually, with the patient's name on the cover. In each case, Freud filled out two pages of pre-printed physical examination sheets, then wrote ten to twenty pages of progress notes. The file's progress notes—exceptionally extensive, yet clinically detached—surely represent the first draft of the modernist case study, which soon diverged in style, scope, and mandate. In 1904, Freud gave his last lecture to a medical audience; in 1905, he stopped publishing in medical journals.¹⁴

The modernist case study and administrative case file, both pedagogic instruments, accumulate dissimilar collectives or publics.¹⁵ The exemplary psychoanalytic case is addressed to a bourgeois readership interested in new explanations of their mental constitution and the nature of psychological and sexual individuality. Through the process of interpretation of such closed, retrospective narratives, modern subjects can self-consciously reframe their complex selves, entering into the field of psychoanalytic interiority. In contrast, the case file becomes part of the machinery for making individuals into normative collectives, for rendering them bureaucratically knowable and serviceable.¹⁶ Case files are interoceptive, evolving, often het-eroglossic documents, oriented toward the future, shaping the prognosis. Sometimes, as a form of closure, the file can be written up and published as a case report, perhaps even turned into a psychoanalytic case study. Although related, locating identity in a case study and finding it in a case file are distinct disciplinary maneuvers, one promiscuously generating subjectivities, the other serializing clinical objects.¹⁷

The Unit System

Since Hippocrates, European medicine has used exemplary cases to structure and inform clinical reasoning. Explaining cases proved an especially powerful pedagogical technique, a conceptual tool demonstrating the natural course of disease, the means of diagnosis, and the effects of therapeutic intervention. But the case record did not become a bureaucratic instrument until the nineteenth century. Even then, most hospitals failed to keep systematic records. The Massachusetts General Hospital, established in 1821, appears to have been unusually rigorous initially in registering and documenting the histories of the patients on its wards. From 1837, a daily progress report was required for each patient, noted in the hospital casebook, which was ordered chronologically. Physicians sought to simplify and standardize accounts of the presenting complaint and the personal history, to make them brief, pithy, and comparable. The tally of findings on physical examination also became more succinct and coded, less impressionistic, and more evidential or “objective.” By the 1870s, the record contained charts for respiratory rate, pulse, and temperature. Later still, standard forms for new laboratory tests, for biochemical, bacteriological, and radiological results, became available. Photographs might even appear in its pages. The hospital appointed its first custodian of records in 1897, but only after 1904 were records kept systematically for outpatients.¹⁸ These changes in the patient record represent, according to medical historian John Harley Warner, “the emergence and consolidation of a new epistemological and aesthetic sensibility, expressed as a narrative preference for what was universal and precise over what was individual and discursive.”¹⁹

At the beginning of the twentieth century, the case report emerged as a recurrent motif in medical training.²⁰ In the 1870s, Christopher C. Langdell had introduced the case method of teaching to the Harvard Law School. Its success inspired a rising Harvard medical student, Walter B. Cannon, to promote around 1900 the use of clinical cases as exemplars in the medical school too. These illustrative cases, expressed in standard and exact form, offered guidance in diagnosis and therapeutics to medical students and young physicians. Cannon extolled the power of cases to “rouse enthusiasm” and their “great value drilling the mind of the student.”²¹ A few years later, Richard Cabot began setting up clinicopathological case conferences at the Massachusetts General Hospital. These turned into gripping performances, where physicians contended with one another in determining correct diagnosis and treatment, learning of their success or failure only when pathologists dramatically provided the answer at the end of proceedings. The record of such case conferences became a regular feature of the Boston Medical and Surgical Journal, later the New England Journal of Medicine. They helped generations of physicians to reason in cases.²²

The transformation of hospitals in the early twentieth century into large, complex institutions with proliferating bureaucracies spurred efforts to reform and systematize record keeping.²³ Gradually, flexible individual case files replaced cumbersome casebooks and bundles. In 1907, the Mayo brothers started a trial of singular records, or unitary files, at St. Mary's Hospital in Rochester, Minnesota. Presbyterian Hospital in New York City made the first major investment in individual records around 1916, as the United States entered armed conflict in Europe. It was the first hospital to demand that information from all clinical encounters in every division be inscribed in a single file, assigned a serial number, which could be supplemented on further admissions.²⁴ Unlike the casebook, the “unit system” exerted considerable influence on clinical work, aiding the coordination of multiple specialists in the bureaucratic hospital and clarifying the illness trajectory of their patients. Although physicians remained the primary authors, other groups within the hospital, including nurses, could contribute to limited parts of the file. The unit record collated the patient's history, examination, test results, clinical progress, through multiple admissions; correspondence and administrative forms, some in typescript, soon attached to it; and it came to serve both as aide-memoire and prognostic indicator for the doctors managing the case. (Particularly thick case files, and multiple volumes, did not augur well.) Before long, other hospitals were following Presbyterian's lead—and not just in the United States.²⁵ We know that Canadian, British, and Dutch hospitals took up the unit record system in the 1920s. “The explicit discussion and implementation of novel record-keeping methods occurred first in the United States, and then spread to Europe,” according to Stefan Timmermans and Marc Berg. “Hospitals in Europe followed suit in remarkably similar ways.”²⁶

The new paper technology not only defined more coherently the case, thereby re...

Table of contents

• Cover
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Acknowledgments
• Introduction: Case Studies and the Dissemination of Knowledge
• PART I Case Knowledge
• PART II Historical Cases
• PART III Literary Circulations
• Contributors
• Index