Showing papers in "Literature and Medicine in 1992"

To Build a Case: Medical Histories as Traditions in Conflict

Abstract: Medical practice relies on the incantation, the word that seems to have power by virtue of being said. To say "mitotic figures" confers on the pathologist the dark power of having generated the cancer that he only observes; to write "this unfortunate 72-year-old woman" at the head of a consult note sentences the patient to a slow but certain death; to intone "supratentorial" reduces the patient's symptoms to the ridiculed status of being all in the head; to level "hyporenin-hypoaldo" at a patient with a high serum potassium not only makes sense of the electrolyte abnormality but quasi-magically resolves the unrest that accompanies the lack of pathophysiological containment. Medicine unfolds in its language—its incantations as well as its diagnostic imagery, its syntactical methods of disengaging patient from physician, its undermining subtextual cultural codes that privilege and marginalize. Medical care begins when corporeal events achieve the status of words. The secrets of medicine, therefore, are bound up in its language; decoding the elements of medicine's language may, pari passu, decode the fundamental nature of medicine. To label a medical history a narrative and to call the act of diagnosis a hermeneutic project are not incantatory acts that by themselves transform medicine. There is no magic in the application of literary terms to medicine, but there may be power in excavating the foundations of medical thinking and action that are thereby exposed.

Historiography, Diagnosis, and Poetics

Abstract: Physicians began to record case notes and, in consequence, medical practice became a fundamentally discursive enterprise perhaps as early as the first appearances of the Asclepian temple inscriptions and of the forty-two case histories that make up Books 1 and 3 of Hippocrates' Epidemics. However, the written records kept by physicians were not fully instrumental in the professional institutionalization of medicine until the end of the eighteenth century. Recently, scholarly and critical attention has been turned to the signifying practices and to the poetics of the clinical case history, or, as the neurologist Oliver Sacks calls it, the \"clinical tale.\"1 But this attention also raises some problems. Medical narratives cannot easily be read as literary artifacts, and the methodologies of literary criticism employed to scrutinize them, without neglecting their foundation in the experience of the body and in the social and medical roles of clinical diagnosis. We need, rather, to investigate the conventional structures of casehistory writing in their clinical context to understand how the fundamental linearity of the patient history derives from the reconstituted and unified story it contains. In this reconstitutive process authority is displaced from the case historian to the text.2 By discussing the history in relation to theories about other kinds of narrative—historical, anthropological, and literary—this essay examines the patient history as a way of knowing the human body and the human being. I shall argue that the patient history depends for its structure on a codified narrative form

Patient stories, doctor stories, and true stories: a cautionary reading.

Abstract: Over the past twenty years, medicine and medical education have increasingly—and commendably—emphasized the importance of treating the whole patient and the importance of listening to stories as ways of understanding patients and their illnesses more fully.1 This emphasis has allowed physicians to rethink what can (and frequently has) become primarily a technical practice and to return to the healer's values once characteristic of general practitioners but newly recognized as effective across specialities. As Arthur Kleinman observes, talking with patients about their particular experience of illness becomes a kind of \"witnessing,\" an encounter that helps patients \"to order that experience\" and one that \"can be of therapeutic value.\"2 What George L. Engel first termed in 1977 the \"biopsychosocial model\" of health and illness is slowly replacing the biomedical model as the dominant explanatory model in Western medicine.3 This model permits and encourages physicians to take into account the many critical factors in patients' lives and health that go beyond the purely mechanical or chemical. Howard Brody, Arthur Kleinman, Eric J. Cassel, and many others have argued that factors such as stress and social support, economic realities, the psychological impact of illness, and the like can all be addressed in the care-giving relationship through this model, and that attention to such factors can significantly affect health.4 In many respects, the biopsychosocial model is a medical breakthrough; in other respects, it reflects timeless knowledge of the relationships among mind, body, and the healer's art.5 For patients, the explanatory model adopted by their care-givers delimits the care-giver's intrusion into private realms. In many cultures, for example, healers have access to patients' dreams, family quarrels, and spiritual lives without necessarily being afforded the full range of

Remaking the case.

Abstract: Narrative persists in medicine, as it does in the human sciences generally, as both a source of information and a means of organizing its interpretation. Unscientific though narrative may seem, the case is not only a record of medical attention provided a patient, but the fun- damental unit of medical discourse and the pattern for clinical reasoning. With its hypothetical, testable, diagnostic plot, it enables the physician to apply the nomothetic principles of biomedical science to the patient's idiographic manifestations of illness.1 Like thinkers in other fields that rely on cases—law, moral theology, criminal detection—physicians rea- son backward from effect to cause by constructing from the signs (or clues, facts, evidence) a probable narrative whose validity can be tested by further interrogation of the phenomena. Neither so satisfyingly co- herent as fictional narrative nor so epistemologically secure as the repli- cable demonstration of scientific fact, the medical case lies somewhere between the two. It is, in short, history. As a working part of the process of diagnosing and treating disease, the case aspires to scientific rigor. But the epistemological shift that in the late twentieth century has called into question the simple, objective, logical-positivist view of knowl- edge—medicine's working epistemology—has affected the way we think about case history, too. No longer taking the Newtonian physical sci- ences as the sole pattern of rationality, thinkers have turned in recent years to the contextual, interpretive methods of knowing that are char- acteristic of the social sciences and the humanities. Narrative is one of the chief of these. Not surprisingly, then, recent changes in the case

The politics of narrative form.

Abstract: published in the last fifteen years demonstrates strong concern for humanizing medical education. Proponents recognize the potential narrowness of an overly scientific curriculum that tends to suppress imaginative responses to deeply personal human situations. Literature and medicine has been offered as, among other things, a way of countering physicians' patriarchal attitudes, the treatment of patients as objects (or symptoms), and the loss of a sense of the broader cultural implications of disease and healing, and as a way of addressing the need for nurturing rather than professional brusqueness. I would add that studying literature in medical school can also repair the image of today's medical professionals who no longer live up to the great humanist figures of earlier centuries.2 Although most educators agree that simply reading some fiction will not heal these ills, many see literature as an important way of reinscribing a form of moral philosophy in the medical curriculum and developing a sensitivity to narrative as well as scientific ways of knowing. Nevertheless, advocates of such programs should not naively assume that literature transcends the problems that accompany an overly scientific medical education. Literature can (possibly) promote sympathetic responses to human situations and consequently help to humanize medical practitioners; but, on another level, narrative form produces, influences, shapes, and constrains knowledge in some very particular,

Is there a person in this case

Abstract: The clinical case report serves a fundamental role in patient care and medical education by organizing knowledge about a patient into a standardized form. Whether written or oral, the form is fixed and consists of the following elements: the chief complaint, followed by a history of present illness, past medical history, social history, family history, review of systems, physical exam, results of tests, assessment, and plan. To question or suggest altering the case report would be regarded by most physicians as trying to fix what's not broken. Yet some critics are challenging the worth of this sacrosanct form. We agree with those who argue that the case report uses and legitimates deleterious, even degrading, terminology, that it encourages hasty categorizations and excludes the voice of the patient. The form also emphasizes description (often numerical data) at the expense of storytelling and biomedical objectivity at the expense of empathy. In short, the case report has become the story of a mechanistic entity, a biomedical body. It seems fair, then, to modify a locution of Stanley Fish and ask, \"Is there a person in this case?\"1

Development of the physician's narrative voice in the medical case history.

Abstract: When I heard the learn'd astronomer, When the proofs, the figures, were ranged in columns before me, When I was shown the charts and diagrams, to add, divide, and measure them, When I sitting heard the astronomer where he lectured with much applause in the lecture-room, How soon unaccountable I became tired and sick, Till rising and gliding out I wander'd off by myself, In the mystical moist night-air, and from time to time, Look'd up in perfect silence at the stars. —Walt Whitman, \"When I Heard the Learn'd Astronomer\

Charting the chart--an exercise in interpretation(s).

Abstract: The multiauthored article is standard in the medical sciences, where the politics of the laboratory and the academy often loom larger than the singularity of the argument or grace of its execution. The following paper, however, depends upon the singularity of each of its authors and hails the individual grace of their arguments. Although collaborative, this paper is primarily collective, composed of unique readings of the same document. In its array of individual viewpoints and interpretations, it underscores the collective nature of the entries that constitute the single entity identified as the chart. As the record of one patient's hospitalization is really a diverse collection of individual voices as well as professional interactions or viewpoints, so the responses of these readers are unique to each one's personal and professional backgrounds.1 —Suzanne Poirier, Ph.D., Literature2

Winged Words and Chief Complaints: Medical Case Histories and the Parry-Lord Oral-Formulaic Tradition

Abstract: Imagine the following story: A very young man who is a renowned warrior enlists with the Greek army attacking Troy. This warrior has been told by his divine mother that he has one of two fates in store for him—either a very long, peaceful life or one shortened by death in battle but lengthened by immortal glory. The commander-in-chief publicly insults and humiliates the warrior by stripping him of a slave girl the warrior has rightfully won as part of his spoils from the ongoing war. The warrior retreats to his camp, depriving the commander-in-chief not

Beloved illness: transference love as romantic pathology in F. Scott Fitzgerald's Tender is the night.

Abstract: When Tender Is the Night was first published, in 1933, literary critics praised Fitzgerald's \"method of dealing with sickness material\" in the novel.1 More recently, however, critics have emphasized the author's superficial understanding of psychiatry. Among these is Jeffrey Berman, who convincingly establishes Fitzgerald's lack of knowledge about \"the theoretical and clinical intricacies of transference love\" and Dr. Diver's

Charting Dante: the Inferno and medical education.

Abstract: ion. In maintaining that there are grounds for a comparison between the Inferno and contemporary medicine, I am not in any way condoning the view that disease is a sign of sinfulness or the notion that treatments given patients are often torments inflicted as punishment—though such views are, regrettably, a part of the legacy that has come down to us under the general rubric of Western culture. What I propose here is an analogical study of the Inferno—a reading that considers the text analogous in certain ways to the world of medicine. Thus Dante's journey through Hell can be seen as analogous to the medical student's journey through medical school, or even to the physician's maturation and development in his or her profession; sin can be seen as analogous to disease; punishment in Dante's system can be viewed as analogous to medical treatment. An analogical reading such as^ this is one that assumes an overall likeness between two constructs, or systems, and then proceeds to explore the meaning of those likenesses as they unfold in the developing textual narrative. On the literal level, the Inferno describes the journey of the pilgrim Dante into and through Hell. Reading the Inferno is primarily an act of the imagination: the reader must descend with Dante the pilgrim down through the nine circles of the inferno and learn, by experiencing it, the topography that is itself the primary metaphor of the poem's meaning. A construct of the scholastic imagination, Hell is organized around the three Aristotelian categories of Incontinence, Violence, and Fraud. Upper Hell is populated by sinners guilty of the sins of Incontinence (lust, gluttony, wrath); Lower Hell is the abode of those being punished for the more serious sins of Violence—the murderers and suicides, and, still further down, those guilty of the sins of Fraud and Malice—seducers, simoniacs, and traitors. The descent, then, is a moral one: the deeper we penetrate the depths of Hell, the worse the sin.

Tragedy of the commonplace: the impact of addiction on families in the fiction of Thomas Hardy.

Abstract: [I]n perceiving that taste is arriving anew at the point of high tragedy, writers are conscious that its revived presentation demands enrichment by further truths ... : treatment which seeks to show Nature's unconsciousness not of essential laws, but of those laws framed merely as social expedients by humanity, without a basis in the heart of things; treatment which expresses the triumph of the crowd over the hero, of the commonplace majority over the exceptional few. —Thomas Hardy, \"Candor in English Fiction\"1

"A Case of Amyotrophic Lateral Sclerosis": A Reprise and Reply

Abstract: . . . [EJvery . . . patient is thrown into a \"tale,\" a real-life narrative or drama, whether he knows it, or likes it, or not. He is thrown into the problematic, and thrown into the dramatic—this being an essential horror, or privilege, of being sick. And the problematic and the dramatic are fused together, so he finds himself playing the central (and sole) role in a philosophical or symbolic drama. Case histories, while indispensable, do not move at this level; they go no further than the historical presentation of disease. They are wholly descriptive, not narrative or dramatic. They do not present \"patienthood,\" but only \"casehood.\" They do not show us the patient thrust into a role—nor the fateful character of sickness, which imposes on him roles. The idea of fate, hence of existential drama, is missing from case histories. It is only in a fully narrative form—a clinical tale— that the subject, his \"fate,\" the drama of his existence, can be exhibited in all their fullness and force.1

Trials, Tribulations, and Celebrations: African-American Perspectives on Health, Illness, Aging and Loss (review)

Abstract: has suffered in conventional literature courses, the inaccessibility of resources for teachers on many medical campuses, and the cumbersome and often costly obstacles of copyright laws all contribute to an alarming paucity of ethnic Uterature in courses in the medical humanities. Trials, Tribulations, and Celebrations thus expands the field of medical humanities in an important way. Marian Gray Secundy and her collaborator, Lois LaCivita Nixon, acknowledge that they can offer only \"a beginning, an attempt to provide a wide selection of imaginative works describing the circumstances under which African-Americans live and the values that