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CLINICAL NOTES
John Forrester (1996). ‘If p, Then What? Thinking in Cases,’ History of the Human
Sciences, 9:3, pp. 1-25.
What does it mean to think in cases?
This is a question that all clinicians would have asked themselves every now and
then. That is because they would have been confronted in the first instance with the
generic differences between clinical notes, case notes, and case studies.
These clinical notes will attempt to differentiate between these genres.
Clinical notes are an attempt to extract the basic approaches to clinical work from a
range of different sources.
Case notes pertain to the description of the ailments, symptoms, and the
observations made by the clinician relating to the diagnosis and prognosis of the
patient when the treatment is in progress.
Case studies relate to a full-fledged description of an illness in a particular patient
which depicts the onset of the illness; the symptoms that constitute it; the tests and
exams that were conducted; the patient’s responses to these tests and exams; the
diagnosis, the prognosis; and the eventual outcome of the treatment.
What case notes and case studies have in common is that they are an attempt at
writing a singular narrative.
They take up the task of making professional interventions at the level of what
Aristotle would term ‘practical wisdom.’
Readers who are interested in analysing these generic differences and the questions
that will arise in their minds from the pursuit of practical wisdom in professional
discourses like law, medicine, and psychoanalysis will gain a better understanding
of what is at stake in ‘thinking in cases’ if they read John Forrester’s work in this
area.

2. 2
These clinical notes summarize some of the main points raised in John Forrester’s
paper. These notes do not review his paper in its entirety, but raise only those points
that relate mainly to the needs of the psychoanalytic clinic.
The main question that John Forrester answers in this paper is one that he gets asked
repeatedly as a historian and philosopher of science. This question relates to whether
psychoanalysis itself is a science.
Forrester’s response is to usually respond with a question of his own. That question
is: ‘Is jazz serious music?’ In other words, the answer is: yes and no.
Those who ask this question have a ‘positivistic’ notion of science and do not
understand the long history and philosophy of science themselves.
But John Forrester takes this question seriously.
In the attempt to answer it, he invokes a concept from the work of Ian Hacking who
is best known for his history of statistics.
Ian Hacking argues that science does not unfold as an expression of positivism as the
layperson might think, but uses a number of styles of reasoning.
Hacking identifies at least six such ‘styles of reasoning.’
These six styles of reasoning, according to John Forrester, are the following:
‘postulation and deduction; experimental exploration; hypothetical construction of
models by analogy; ordering of variety by comparison and taxonomy; statistical
analysis of regularities of population; historical derivation of genetic development.’
What John Forrester does is to introduce another style of reasoning to this list; the
seventh item as it were: ‘thinking in cases.’
Situating this approach within those made available in Ian Hacking’s typology of
styles of reasoning should make it possible for the clinician to attain greater clarity
on why he lives in a world of clinical notes, case notes, and case studies.
These genres are what make it possible to encompass the clinical phenomena that he
or she is subject to when they analyse or treat a patient.
The question of whether clinicians should focus on individual cases or not is not
difficult to answer; they should since they have a legal and moral obligation to do so.
The underlying anxiety really is at the level of whether seeing patients is the same as
doing science (since a constant preoccupation in the history of philosophy is to relate
individual cases to the category that they come under).

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So, for instance, does a particular case come under a particular category that names
the illness?
If so, should the clinician respond to the patient as merely somebody who belongs to
a particular nosological category?
Or is it rather the case that the patient should be responded to as a singular instance
deserving of singular treatment?
This is a problem that was addressed by Hippocrates himself when he reminded
physicians on the difference between treating the patient and treating the illness.
It also addresses the psychological difference between a physician who can ‘heal’ the
patient and the physician who tries to ‘cure’ the patient of his illness.
This is another version of whether a management consultant, for instance, should
offer a standard solution to a client’s problems or whether he should offer a tailor-
made solution.
In both cases, the question is whether what is being sought is scientific knowledge
that can subsume individual variations or whether what is sought is a form of
practical wisdom which constitutes knowing that ‘different folks require different
strokes.’
When John Forrester delineates the history of the case method in law and medicine,
what he is basically saying is that the case method is deeply implicated in the pursuit of
practical wisdom.
The attempt to apply a general approach to all clinical work and reduce the patient
to the membership of a particular category leads to a form of methodological
casuistry.
John Forrester argues that such an approach is based on a fundamental
misunderstanding of what a science is.
It fails to differentiate between scientific discourses that try to generate knowledge
and professional discourses that try to solve problems.
This is akin to the position that was staked out by Jacques Lacan as well when he
advised analysts that they should treat every patient as though they did not know
any analytic theory at all and were seeing their very first patient.
In other words, what makes the patient singular should not be forgotten. It could
serve as the crucial pivot for a clinical intervention.

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Jacques-Alain Miller also makes a similar point when he argues that if the patient
suspects that the clinician is taking a reductive approach, then, he will try to ‘falsify’
the analyst’s interpretations.
This is tantamount to a form of acting act in which the patient feels that the analyst is
not really listening to him.
But the real twist in the tale – as John Forrester depicts it – is not the fact that the case
method serves the professional well in his practice, but that it has profound
implications for how professionals in law and medicine are trained.
The case method then becomes a form of cognition; singular cases have become units
of cognition; the method has its uses both for research and teaching.
John Forrester analyses how this method became dominant both at Harvard and
Cambridge for teaching law and medicine before concluding that what differentiates
the Anglo-American approach from the European approach is that the former does
not believe that the law or medicine is reducible to a code.
In other words, what is required of the philosopher of science, as John Forrester puts
it, is to formally represent:
‘the specific modalities – historical, epistemological, political – by which reasoning in
cases, descended from Aristotle’s practical wisdom, has been embedded in
disciplines and practices that we recognize as the domain of the expert, the
professional, in the human sciences, sciences which, to encompass the scope that
case-work has now acquired, must be allowed to include medicine, law, philosophy,
- and the therapies of the word.’
These clinical notes, like the genres of case notes and case studies, are a gesture in
that direction.
SHIVA KUMAR SRINIVASAN