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Medical Essay

The history of medical narratives stretches back to the earliest days of medicine itself, with two streams sometimes interwoven: the case history and the first-person narrative of illness. Case histories have always been part of medical practice, though observations have always been informed by theory—whether the humoral theory of ancient and medieval medicine, the germ theory of i^th- and zoth-century medicine, or the emphasis on hormones and subcellular processes in the medicine of the last quarter of the 20th century.
Hippocrates, the leading figure in classic Greek medicine, advocated treating the individual rather than the disease, and treating the whole body rather than a part of it. Yet the humors theory attributed to Empedocles was incorporated into Hippocratic writings and, continuing through Aristotle and Galen, became the shaping theory throughout the Middle Ages (when the main interest was in the afterlife, and little attention was given to the human body) and even beyond. In the 17th century a return to Hippocratic medicine brought renewed interest in observing and talking with patients and thus a revival of the case history. In the 18th century, organized records were stressed, with the goal of collecting and classifying data. Only in the late 18th century, as diagnosis began to depend less on theory and more on observation, was the patient’s narrative considered essential to diagnosis. Significantly, this period was also one of a major flowering of prose, when the narrative of the novel became accepted as a literary form. Coincidentally, as narrative gained cultural authority, so did the physician. Observing patients and compiling case histories was part of the 18th-century physician’s training, and recorded observation played a major role as clinical medicine and statistics evolved.
In the movement toward the clinic as a vehicle for teaching, Michel Foucault (in Naissance de la clinique [1963; The Birth of the Clinic]) perceived a shift in the very epistemology of medicine, a shift to seeing—observation—as the basis for knowing, with the accompanying recording of what was seen. If the focus of medicine in the 18th century, then, was classification, in the 19th century the case history became more elaborate. A standard case history format was codified by the end of the century; it included identifying data, chief complaint, history of the present illness (HPI), patient’s history, review of bodily systems, family history, and social history. The HPI required writing in sentences—thus contributing to an overall sense of coherence. Still, illness was somehow separated from the patient—at least for purposes of analyzing, classifying, and prescribing treatment.
In recent years, Lawrence Weed’s “SOAP” approach has adopted a four-part medical history: “Subjective” details (the patient’s history), “Objective” data (clinical observations, technological studies), “Assessments” (relying heavily on clinical observations and technical studies), and “Plans.” In Weed’s formula, personal history still retains the narrative element, but the language has become conventional as the structure has become prescribed, though the chief complaint is expected to be given in the patient’s own words. The 20th century has seen the case record moving from the patient’s history and the physical examination to reports of technical studies and imaging and then to intervention through technology. The contemporary case history has a seeming neutrality, even a lack of the humane—a lack that has spurred attempts to reinforce the history of the patient. However, as literary and linguistic theorists have demonstrated, no narrative is valuefree; the medical case history, like any other narrative, is subject to the privileging of the author’s voice and perspective. Yet, even as the case history moved toward codification, the second stream of medical narrative continued, the tradition of personal accounts of illness. From medieval accounts of the massive spread of, and terrible suffering from, bubonic plague to John Donne’s and Izaak Walton’s 17th-century accounts of illness, and Samuel Johnson’s account in the 18th century of his paralytic stroke, this genre has held the interest of the reading public. From the late 18th century through the 19th, illness narratives and books of popular advice had wide appeal. Among the Romantics, Coleridge wrote of his poetic depression and physical pain, Thomas De Quincey described the pains and dreams associated with his use of opium, and Coleridge’s daughter Sara wrote of her own bouts of depression and confrontations with cancer. The Romantics wrote of Nature in grandiose terms as a sympathetic and protective force, though illness narratives such as Sara Coleridge’s seemed to struggle with such a concept in the presence of real suffering.
In the later 19th century a case history was often used as a warning, particularly against the dangers of excesses, as well as advice on the virtues of moderation. “Nervous” tribulations were frequently the subject of medical essays in this period, which was fascinated by electrical explanations of the nervous system. In the tradition of tracing “nervous” maladies, and in a quest for understanding the whole patient through reconstructing the life story, Sigmund Freud effectively created a new science rooted in narrative, and in the course of this brought the case history to perhaps its highest artistic state. In Freud’s hands, psychoanalysis was, indeed, more art than science as he led the patient (and the reader), in his terms, out of the forest and into the open space where all could be seen clearly as a whole, where dreams could be understood as, primarily, visual pastiches of experience. In his attempt to “decode” what the “dreamwork” had wrought,
Freud took his readers through labyrinthine paths as he explored dreams in terms of the unconscious and of wish-fulfillments, and as he devised a whole new vocabulary for the workings of the unconscious: condensation, displacement, symbolic representation, and regression, for example. Freud’s memorable tales of Dora and the Wolf Man, of the burning child who appears in his father’s dream, and of his own young daughter’s dreams of strawberries have enriched the history of the medical narrative and set precedents for contemporary medical essays.
With the increasing emphasis on the technical and on clinical language, the physician has become distanced from the narrative that seeks to present the patient as a whole. In the last quarter of the 20th century, however, the non-technical medical essay has achieved an unprecedented popularity. As a genre, the contemporary medical essay goes beyond the case history to explore the physician’s voice and perspective, the physician becoming a persona who makes observations of patients, of medicine, of the world as seen through his or her eyes. As the medical essay attempts to present the human side of medicine, it returns to medicine as an art, attempting to replace or supplement the cold anonymity of the professional medical narrative. A good example is the work of Lewis Thomas, who began writing brief informal essays for the New England Journal of Medicine in 1971; their popularity has led to several collections, beginning with the award-winning The Lives of a Cell: Notes of a Biology Watcher (1974). Thomas brings his perspective as a clinician and epidemiologist to both medical and nonmedical subjects—from subcellular particles to the earth itself, considered as a kind of cell. He brings humor to his essays as he writes about our fascination with killing germs (especially our own) with antiseptic sprays that are given miraculous attributes in television commercials. Subjects ranging from medical history to warts, and to the way in which cells in the embryo “switch on,” call forth Thomas’ speculations and reveal his sense of wonder at life and its almost magical qualities.
The most sophisticated medical essays to emerge in the late 20th century often focus, as do many other literary and philosophical texts, on the role of language in conveying knowledge, emotion, and understanding. Thomas demonstrates his fascination with language, exploring the paradox that we can only consider language through language, using the brain to think about how the brain works. More literary and more seriously philosophical in his approach is Oliver Sacks, who also considers the role of language in medicine and attempts to break away from the fragmented, particularized approach to understanding as embodied in the Cartesian-Newtonian world view. This world view, accepted as modern medicine emerged, remains the basis for the analytical (and reductionist) breaking down of the medical condition into its component parts, isolating and treating the causative agent. Sacks has argued that medicine needs to turn to the everyday language—what he calls “metaphysical” language—that we use for things not measurable, and that modern medicine, ostensibly objective, and focusing on “subjects,” carries dangers in that the war metaphors and notions of disease as alien and evil are not questioned. Narrative and drama, Sacks contends, are paths that lead back to the concrete; he looks to a holistic language to encompass both the individual patient and a larger view of the natural environment.
Sacks explores a variety of human conditions for their uniqueness and their instructiveness about the human body. In Awakenings (1973, revised 1976, 1982., 1991) he writes of patients who were brought back from unconscious states by the drug L-dopa, tracing with insight and sympathy the seeming return to life of these patients and also the relapse into arrested consciousness that many later experienced. In The Man Who Mistook His Wife for a Hat (1985), Sacks explores the often bizarre behavior of otherwise normal human beings whose perception of their surroundings is altered by neurological deficiencies—as in the case of the title character, who could deal with the world through singing, but who confused his foot with his shoe and seemed to confuse his wife’s head with his hat. In other books he explores migraines as perceived today and throughout history, the culture of the deaf whose linguistic abilities are richly manifested in the visual language of Sign, and his own loss of proprioceptive awareness of self after a broken leg.
Richard Selzer employs in his writing the grotesque and the shocking, often juxtaposed with scenes of striking tenderness, to bring the reader into the realm of the living, bleeding human body. From the grotesquerie of the gangrenous limb upon which the patient had drawn a smiling face to the tenderness of a surgeon who slipped back (because the child’s mother wanted her to be beautiful in the afterlife) to repair the cleft lip of a patient who died unexpectedly from anesthesia, Selzer explores the human body in all its decrepitude and beauty. Yet beneath Selzer’s descriptions of grotesques there is an almost metaphysical quest (though he declares that he has come to believe there is only the flesh), a quest for meaning in the body, for what he calls “The Exact Location of the Soul.” In Selzer’s texts there is also a quest for meaning in what he does: he takes the word “doctor” to its Latin root meaning “leading” or “teaching” as he explains that he writes because he wants “to become a doctor.”
Less philosophical than Sacks, and less focused on the grotesque than Selzer, but consciously admitting an element of mystery into his clinical tales, is Harold Klawans, who speculates half in jest in Newton’s Madness (1990) on the effect of diagnosis on illness, with a nagging doubt that disease undiagnosed may not really be disease. Like Sacks, Klawans explores the human side of neurological disorders (in Toscanini’s Fumble [1989] as in his other books) and provides notes to the medical literature; like Thomas, he pursues the etymology of words; like Selzer, he approaches life as mysterium, as something to be admired and not reducible to a neutral language.
These last three writers are representative of a number who tackle the many aspects of the “human” side of medicine. In addition, the late 20th century has also seen a resurgence of the first-person narrative of an individual’s encounter with illness, though the focus has now come to include the healthcare system. These narratives, or essays, though not structured in the manner of an essay written by a trained medical observer, have nevertheless contributed to a growing awareness of the importance of the medical essay and of its nature as a construct, rather than a straightforward presentation of objective fact. Although these “pathographies,” as Anne H. Hawkins (1993) describes them, are often autobiographical, they may also be considered as indicative of the breadth in scope of the medical essay that has gained it such popularity in recent years.

MARY ELLEN PITTS

Anthologies
Surgical Case-Histories from the Past, edited by Harold Ellis, London and New York: Royal Society of Medicine Press, 1994 Tenetments of Clay: An Anthology of Medical Biographical Essays, edited by Arnold Sorsby, London: Friedmann, 1974; New York: Scribner, 1975

Further Reading
Ackerknecht, Erwin H., A Short History of Medicine, Baltimore: Johns Hopkins University Press, revised edition, 1982. (original edition, 1955)
Baron, Richard, “Bridging Clinical Distance: An Empathic Rediscovery of the Known,” Journal of Medicine and Philosophy 6, no. 1 (1981):5–23
Brody, Howard, Stories of Sickness, New Haven, Connecticut: Yale University Press, 1987
Charon, Rita, “To Render the Lives of Patients,” Literature and Medicine 5 (1986):58–74
Charon, Rita, “To Build a Case,” Literature and Medicine 11, no. 1 (1992):115–32
Engel, George L, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196 (1977):129–36
Epstein, Julia, “Historiography, Diagnosis, and Poetics,” Literature and Medicine 11, no. 1 (1992):23–44
Hawkins, Anne Hunsaker, Reconstructing Illness: Studies in Pathography, West Lafayette, Indiana: Purdue University Press, 1993
Hilfiker, David, Healing the Wounds: A Physician Looks at His Work, New York: Pantheon, 1985
Hunter, Kathryn Montgomery, Doctors’ Stories: The Narrative Structure of Medical Knowledge, Princeton, New Jersey: Princeton University Press, 1991
Mishler, Elliot G., The Discourse of Medicine: Dialectics of Medical Interviews, Norwood, New Jersey: Ablex, 1984
Psaty, Bruce M., “Literature and Medicine as a Critical Discourse,” Literature and Medidne 6 (1987):13–34
Rocher, Gregory de, “The Renaissance Wound: The Discourse of Power in Sixteenth- Century Medicine,” Romance Quarterly 38, no. 2 (1991):131–37

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