Clinical Tales

^Clinical Tales Oliver Sacks I have subtitled a recent bookJ "Clinical Tales," a term which might seem willful oxymoron to some; to me it seemed entirely natural, indeed unavoidable, for the sort of narratives I presented. But what is meant by the term? And what relation has it to "case history," on the one hand — and to "literature," on the odier? Such tales are "clinical" insofar as they have a factual, clinical basis, and lend diemselves to a clinical or medical analysis. And they are "tales" insofar as they have a subject — and a theme — neither of which is possessed by a description or case history. Whedier or not diey may be considered a literary genre must depend on one's definition of "literature," and is not a question I feel competent to explore. I myself have no "literary" aspirations whatever, and if I write "Clinical Tales" it is because I am forced to; because they do not seem to me a gratuitous or arbitrary compound of two forms, but an elemental form which is indispensable for medical understanding, practice, and communication. In the first place, it is die form which patients adopt when they present themselves, in distress, to their doctors. The patient presents a medical "history" — a story of how he or she has been feeling, what he or she has been experiencing, in die realm of "illness." A decision has already been made, perhaps unconsciously, in going to a physician, rather than, say, a priest. There is already a presentation or categorization of oneself as "sick," radier dian, say, 'sinful." This categorization is further focused by the physician himself, with his selective questions and observations, his own concepts or models of disease, which die patient, in his innocence, or ignorance , may not share. The patient presents his "story" with a naive immediacy and force — this is what he has been experiencing, been feeling; the physician (it is to be hopedl) listens not just sympadietically but knowledgeably, with a knowledge of odier "cases," and of the physiological and padiological processes of die organism, which he is able to correlate , creatively, with what the patient is telling him. The patient presents himself as a patient, a sufferer, in die expectation (the hope, die dread) that die physician, an expert, will detect characteristic features, perceive him as a "case," for it is only when a "case" has been delineated — Luria would Literature and Medicine 5 (1986) 16-23 © 1986 by The Johns Hopkins University Press Oliver Sacks 17 say here a "syndrome" — that an appropriate "treatment" can be suggested. Thus the first act of medicine is to listen to a personal story, extract or abstract from it a (syndromic and etiological) "case," and exclaim "Migraine!", and "Parkinsonism!", with all diat this implies. Is this an adequate formulation? It is, perhaps increasingly, accepted as such in our technological age, but in a way which causes a rift between patients and doctors, and, at a deeper level, the loss of some important reality. The rift, the distress, is analyzed by Schwartz and Wiggins,2 and was expressed by Auden in a poem addressed to his own doctor: The specialist has his function, but, to him, we are merely banal examples of what he knows all about. . . . ("Lines to Dr. Walter Birk," lines 9-11) To Hippocrates, the Father of Medicine, we owe the historical conception of disease, which makes a mere diagnosis inadequate by insisting on a total picture of disease (or "pathography," as Freud used the term) - the delineation of an illness course, a history of the illness from its first intimations, through all its subsequent effects and evolutions, to (perhaps) its final crisis and resolution. And, with this, the Hippocratic insistence diat one should not just consider or treat the disease, but consider and treat the diseased individual. Is so doing a sentimentality which modem medicine can do widiout, or is there a deeper sense involved? May it, indeed, be impossible to comprehend the disease, even define it, without reference to die diseased individual? These considerations are brought up, with great force, by McKenzie, writing with regard to postencephalitic Parkinsonism, but in a way which has the most general, epistemological...