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History of medical records

A casebook is a written collection of cases, typically recorded in a series, day by day. Doctors developed this form of writing in Europe in the 1500s. They borrowed scholarly practices of note-taking and mercantile habits of account keeping. They modelled themselves on Hippocrates, the ancient father of medicine, who had reputedly recorded case histories on clay tablets. By writing casebooks, doctors participated in an increased interest in natural particulars. They built on the work of ancient and medieval physicians whose writings detailed remarkable cases and exceptional cures, and, like natural historians, borrowed regimes of sustained observation from astronomers. Note-taking followed conventions, but the habits of speech, writing, and collecting that produced these documents were idiosyncratic.

Surviving casebooks take a variety of forms. Some are like account books, written at the time of the encounter. Others, like journals or diaries, were written when a doctor returned to his study after a day of visiting patients. Some doctors digested their account books or diaries into observations, narrating the history of the disease and cure, then discarded the rougher, more immediate notes. Whatever form casebooks took, they typically included a date, the patient’s name, age, complaint, its causes, a prescription, or a payment.

Around a hundred examples of surviving casebooks have been identified within European archives of personal papers dating from the centuries before 1700. They are often catalogued as account books, diaries, journals, practice books, collections of cures or observations, or casebooks. The term ‘casebook’ was initially used for legal records in the late seventeenth century, then applied to doctors’ notes in the mid eighteenth century. We use it to refer to the range of records that medical practitioners produced when they recorded their practices.

Casebooks, like many other new forms of written documents, were the product of what has been called the first age of information overload. With the shift from expensive parchment to affordable paper, and from laborious gothic to fluid cursive scripts, people wrote more. They developed habits of recording financial, civic and personal accounts and new tools to order, navigate, and preserve the resulting mess of paper. Doctors adopted these new paper technologies to account for, reflect on, and study their practices. The most extensive surviving set of casebooks from this period was produced by the English astrologer-physicians, Simon Forman and Richard Napier.

Further reading

Cite this as: Lauren Kassell, Michael Hawkins, Robert Ralley, and John Young, ‘History of medical records’, A Critical Introduction to the Casebooks of Simon Forman and Richard Napier, 1596–1634, https://casebooks.lib.cam.ac.uk/astrological-medicine/history-of-medical-records, accessed 19 March 2024.