An N of 1: Syndrome Letters in The New England Journal of Medicine

AN N OF I: SYNDROME LETTERS IN THE NEW ENGLAND JOURNAL OF MEDICINE KATHRYN MONTGOMERY HUNTER* Readers ofthe New EnglandJournal ofMedicine cherish, and not always in secret, the occasional letters that boldly claim with tongue in scientific cheek the discovery of a new clinical syndrome or some diagnostic or therapeutic oddity. "French Vanilla Frostbite," "Space-Invaders Wrist," "Credit-Carditis." Narratives of single cases are not unknown in the pages of this bastion of clinical science. Its regularly published clinicalpathological conferences, the "Case Reports of the Massachusetts General [or Beth Israel] Hospital," have been the pattern for medicine's traditional expository narrative since their inception by Richard Cabot 75 years ago, and straightforward syndrome letters published in every issue report unexpected diagnostic and therapeutic phenomena at which we cannot laugh. But the comic syndrome letters are different. They are excessive. Like the straightforward letters they parody, they are written anecdotes, abbreviated narratives of an isolated instance of illness. Their concern with a single, subjectively observed, perhaps cannot -be-replicated case is unscientific on its face. Even more surprising, the serious tone they adopt for their description of an absurd or trivial disorder parodies the investigative spirit that informs theJournal's featured articles, the source of its scientific preeminence. What are these comic letters doing in this place? Because in medicine the New England Journal ofMedicine functions as an arbiter of the acceptable (rather like the commissioner of baseball in that other realm of skill and chance), we must assume narrative reports with an ?7 of 1, comic as well as straight, are in the best interests of scientific medicine. How is this possible? This article is part of a project supported by a grant from the National Science Foundation (Ethics and Values in Science and Technology, RII-8310291) and by a fellowship from the American Council of Learned Societies. The author is indebted to Ellen Key Harris and Pelin Aylangan for research assistance. *Associate professor of medicine, Northwestern University Medical School, 303 East Chicago Avenue, Chicago, Illinois 60611.© 1990 by The University of Chicago. AU rights reserved. 0031-5982/90/3302-0673$01.00 Perspectives in Biology and Medicine, 33, 2 ¦ Winter 1990 \ '2,'il The existence of the comic letters, particularly juxtaposed with their more serious models, nicely addresses a major epistemological problem in medicine. Syndrome letters are a means of conveying information about isolated clinical events, and thus they broaden the practitioner's vicarious experience of new occupational injuries, environmental maladies, and the unexpected complications of therapy. The phenomena they describe are anomalies, exceptions to the rule in a scientific endeavor. But the status of the single case in medicine is a vexed one. What is the relation of this exception to the rule from which it departs? To what degree can it be relied upon? With what confidence can it ever be ignored? Although case reports in essay form have disappeared from most medical journals, the New EnglandJournal ofMedicine among them, letters concerning a single case continue to be published widely and regularly , and those in a few majorjournals are now indexed by the National Library of Medicine. In the New England Journal of Medicine, however, syndrome letters are a minor art form, an often ironic and occasionally self-referential genre of medical storytelling. "French Vanilla Frostbite," for example, reports on inadvertent research conducted at a neighborhood ice cream emporium on a single occasion by two physicians and their infant daughter [I]. "The Tight-Girdle Syndrome" concerns an unusually comprehensive series, as one might expect from its author, Paul Dudley White: he describes three cases, each with its interesting, reportable variation [2]. Like scientific articles, syndrome letters may provoke replies and inspire collaborative investigation. We owe our present-day knowledge of "ski-boot syncope," for example, to the multiletter interdisciplinary discussion inaugurated in the early 1970s by Robert J. Joynt, neurologist, dean, and "skier without parallel" [3, 4]. RegularJournal readers can expect to find such a bagatelle every few weeks, a bit of (usually) diagnostic wit among other, more serious syndrome letters. The serious variety predominates, and, in fact, the comic variants could not exist without a well-established, recognizable, standard form for reporting the nonce case. The...