Editors' Column

^Editors' Column The Art of the Case History is the most focused issue this journal has ever offered. The essayists here analyze one circumscribed aspect of medicine—the conventional narrative act that initiates the formal contact between doctor and patient. But, as the essays make clear, the case history has a complex life of its own that keeps escaping the bounds of convention. The case history is, therefore, a process as much as an object and, if these essayists are correct, it may very well be moving toward a new phase. In its present form, the case history can be described in both structural and functional terms. Structurally, it is an oral or written account of an illness that typically begins with a statement of the chief complaint, proceeds through the history of the present illness, past medical history, review of systems, family history, and social history, and ends with the results of the physical examination and laboratory tests. This is the standard form (with variations, of course) that has served medicine for decades, and it is the genre with which the writers in this issue are most often concerned. In the 1960s, the form was refined in important, persuasive ways by Lawrence Weed, whose "SOAP" approach (see Poirier et al., p. 3) has been widely adopted by clinicians and therefore by some of these essayists. A few other senses of case history are also found here, and they had best be spelled out to avoid confusion. For instance, case overlaps with chart (or progress notes), though they are not quite the same thing. Their relationship is neatly established by Kathryn Montgomery Hunter, who writes that the chart is "the case history in its primary form" (p. 172). Case history is also used to refer to the more flexible narratives written by premodern physicians, such as Galen, and to the vignettes favored by today's medical ethicists. Sometimes, too, the essayists speak of "the expanded case history," a consciously aesthetic narrative of the sort made famous in our time by Oliver Sacks. It supplies information about the physician, the patient, and the patient's family that would not find space—or acceptance—in the conventional form. Sacks, as a matter of fact, has added a fascinating twist to the structural description of all case histories by likening his writing to a palimpsest.1 With this image, Sacks throws the case history right into the laps of certain contemporary Literature and Medicine 11, no. 1 (Spring 1992) vii-xi © 1992 by The Johns Hopkins University Press EDITORS' COLUMN literary critics who speak of "the palimpsestic text"—an apparently single text that conceals a series of shifting, stratified ones.2 The case history should also be described functionally. At its deeper levels, it discloses psychological, scientific, and social purposes, many of which are tacit or unconscious. Its basic psychological goal is probably to establish an implicit contract between a doctor and a patient and, in the process, to serve as a control on the patient's anxiety by lending the doctor a certain authority. For the doctor, the rewards, which are even greater, derive largely from the case history's scientific functions. For instance, because it demands thoroughness and, if done at all well, favors conceptual relatedness, the very form of the case history may save the doctor from falling victim to the fallacy of single cause with respect to a given illness. The form also leads the doctor to choose the pertinent details from among the many that the patient brings into the examining room. Without a case history, in fact, the doctor is like a helicopter pilot searching for a missing boat over open waters; there is little to distinguish between figure and ground; what the pilot sees is all backgroundunfocused , moving water that overwhelms the eye. Furthermore, the case history allows the physician to take action, to move forward—an experience that in all of us seems to encourage a sense of occupational and personal well-being. It does so for the physician by structuring a causal relationship between data gathering and diagnostic hypotheses, and between diagnosis and therapy. In other words, the case history is not a series...