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CASE REPORTS AND MEDICAL PROGRESS ROSSJ. SIMPSONJR.,* and THOMAS R. GRIGGSt A case report is an article that describes an uncontrolled observation in a few patients (generally less than 10) and generally has a characteristic format in which the description of the patient's history, physical findings, results of laboratory tests, complications, and clinical outcome is presented [I]. It is one of the most misunderstood forms of medical communication [2]. Although case reports are the only guide to the study of rare clinical situations [1], are of acknowledged value in teaching and in giving early notice about a new treatment or toxicity [2-4], few physicians appreciate their scientific value. Academicians look askance at colleagues who write case reports, delay reviewing them, and generally reject them for publication . They are often a subject of ridicule [5], and many journals no longer publish case reports [2]. However, this format still remains popular , and over 10% of articles published in the leading medical journals are reports of individual patients, a percentage that has not changed during the past 30 years [I]. Is it proper to allow case reports to comprise such a large percentage of the medical literature? A recent case report from our group, which went through several editors' hands before being accepted, led us to consider the place of the case report in clinical science. We conclude that the attention thatjournals pay to case reports is justified, since certain reports can change our thinking about the pathophysiology of particular diseases and are therefore critical to the advance of medical science. Case reports are often rejected for publication for good reason. There is little justification for publishing a report that does not describe a new The authors thank Dr. Robert Fletcher and Lou Ann Brower for their helpful comments and Donna Goans for her secretarial assistance. Supported in part by National Institute of Health grant no. HL-26484. ""Department of Medicine, University of North Carolina, 349 Clinical Sciences Building 229-H, Chapel Hill, North Carolina 27514. tDepartment of Medicine and Department of Pathology, University of North Carolina, Chapel Hill, North Carolina 27514.© 1985 by The University of Chicago. AU rights reserved. 003 1 -5982/85/2803-0427$0 1 .00 402 I RossJ. Simpson, Jr., and Thomas R. Griggs ¦ Case Reports and Medical Progress observation, that is of excessive length, written in a poor style, or concludes with unsupported or grandiose statements or "clinical implications ." Such writing (and thinking) errors compromise the reliability of the author's observation [6]. Other reasons that case reports go unpublished make less sense. Clinically oriented and young physicians tend to write these reports, and the better reports present new information that challenges existing theories of disease. The reports are often reviewed, however, by editors and physician-scientists who favor the manuscript having literary value, the manuscript from physicians with established reputations, and that propounding already accepted theory [7]. Reports that describe an unexpected phenomenon are often disbelieved or dismissed as trivial. For example, one case report [8] from our group, describing a previously unknown complication of pulmonary embolism, was initially dismissed by reviewers and accepted for publication only after multiple rejections. In contrast, another case report from our group [9], describing an expected complication of ergotamine treatment of migraine headache, was well received and rapidly published. Case reports are also dismissed—unfairly so—as unscientific. A case report describes an uncontrolled observation. It does not test a hypothesis , prove an association, or establish the frequency of occurrence of an event. It only reports an observation and establishes that something can occur. However, such uncontrolled observations of man and nature are important in medical science, as is reflected by the predominance in medicine and biology of the theories of Freud and Darwin —theories that arose from observation and not experimentation. Most importantly, a case report is vital to medical science because it suggests proper and fruitful hypotheses available for testing by the scientific method. Recent conceptualizations of the philosophy of science are helpful in understanding how advances in medicine occur and how the case report may participate in that progress. For example, Thomas Kuhn saw science progress through paradigms, that is, universally recognized achievements of scientists...
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