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^Historiography, Diagnosis, and Poetics* Julia Epstein 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 * A brief version of this paper was presented to the Southern Historical Association in November 1986, and an earlier draft was delivered at Haverford College in January 1987. I am grateful to the many colleagues whose insightful responses on these occasions helped me to refine my thinking. I owe a special debt to M. Elizabeth Sandel for her willingness to read several drafts of this essay. I also want to thank Kimberiy Benston, Janet Golden, Madelyn Gutwirrh, Janet Halley, Elaine Hansen, Judith Schneir Lewis, Nigel Paneth, Ellen Pollak, and Hortense Spillers. Literature and Medicine 11, no. 1 (Spring 1992) 23-44 © 1992 by The Johns Hopkins University Press 24 HISTORIOGRAPHY, DIAGNOSIS, AND POETICS that works with the materials of chronicle, ethnography, and biography.3 Rules governing case reporting play a crucial role in the diagnostic process because the patient history reflects an epistemology of the body. I. Toward a History of Case Reporting To investigate the narrative genealogies and operations of the case history, it is first necessary to trace the provenance of this hybrid form of writing.4 The Hippocratic cases in the Epidemics inaugurate formal case recording in the West, though they remain largely descriptive, and other writings from antiquity, such as the treatise "On the Interrogation of the Patient," by Rufus of Ephesus, suggest that anamnesis is not a modern art. The seventeenth century's renewed interest in Hippocratic medicine—a medical practice based on speaking with and observing patients —turned one of the emphases of medical practice back to history taking and case recording. The Italian iatrophysicist Giorgio Baglivi was an important early modern proponent, along with the better-known physicians Hermann Boerhaave and Thomas Sydenham, of the importance of observation in physic.5 The first specific calls for a systematic record keeping in medical practice came from John Bellers's Essay Towards the Improvement of Physick in 1714, and in 1731 from Francis Clifton's Tabular Observations recommended as the plainest and surest way of practising and improving Physick.6 These systems, however, focused on data collection and correlation: they built nosologies rather than differential diagnoses . The full shift into placing diagnostic importance on a record of the body's story occurred during the later eighteenth century, when diagnosis began to move away from the constraints of the humoral framework, as well as from astrological and iatrochemical theories, and began instead to rely on a combination of the patient's narrative and visual observation. The turn to organized case recording in medical practice coincided with a burgeoning of narrative forms in other cultural arenas; the eighteenth century in Europe witnessed in particular the birth of periodical journalism and the novel.7...

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