To Build a Case: Medical Histories as Traditions in Conflict

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^ To Build a Case: Medical Histories as Traditions in Conflict Rita Charon [T]he question may be raised whether the different aspects of social life (including even art and religion) cannot only be studied by the methods of, and with the help of concepts similar to those employed in linguistics, but also whether they do not constitute phenomena whose inmost nature is the same as that of language.1 Medical practice relies on the incantation, the word that seems to have power by virtue of being said. To say "mitotic figures" confers on the pathologist the dark power of having generated the cancer that he only observes; to write "this unfortunate 72-year-old woman" at the head of a consult note sentences the patient to a slow but certain death; to intone "supratentorial" reduces the patient's symptoms to the ridiculed status of being all in the head; to level "hyporenin-hypoaldo" at a patient with a high serum potassium not only makes sense of the electrolyte abnormality but quasi-magically resolves the unrest that accompanies the lack of pathophysiological containment. Medicine unfolds in its language—its incantations as well as its diagnostic imagery, its syntactical methods of disengaging patient from physician, its undermining subtextual cultural codes that privilege and marginalize. Medical care begins when corporeal events achieve the status of words. The secrets of medicine, therefore, are bound up in its language; decoding the elements of medicine's language may, pari passu, decode the fundamental nature of medicine. To label a medical history a narrative and to call the act of diagnosis a hermeneutic project are not incantatory acts that by themselves transform medicine. There is no magic in the application of literary terms to medicine, but there may be power in excavating the foundations of medical thinking and action that are thereby exposed. Literature and Medicine 11, no. 1 (Spring 1992) 115-132 © 1992 by The Johns Hopkins University Press 116 TO BUILD A CASE Literary critics who study the medical case history have unearthed a playground site of signifiers with contradictory signifieds, rhetoric not conscious of itself, an untranslated heteroglossia that follows Peter Brooks's dictum to "do something." The considerable debt that medicine owes to literature is more than repaid, for medicine offers to the literary critic an interesting case, a discourse that has direct and incontrovertible influence on events outside of itself. A close reading of the written and oral transactions of medicine rewards the critic with a textual anatomy of belief, power, and ontological fears in which the words themselves carry weight.2 What is it that doctors and patients do together? Study of their language reveals that they are engaged in deep conflict about meaning and purpose. Research in doctor-patient discourse over the past twenty years has popularized the concept that doctors and patients perceive different versions of the same events, and that the medical encounter is the field upon which these versions or perspectives meet for reconciliation .3 The notion that doctors and patients develop partnership and collaboration within their relationship conceals the troubling realization that they are undertaking radically diverging enterprises in the medical encounter. Their tasks are not parallel or complementary. The application of complementary models only frustrates the attempt to understand the failure of many medical interactions. Doctors differ from patients in the ways in which they use language and the purposes to which they put words. Doctors use words to contain, to control, and to enclose. When a patient complains of chest pain, the doctor moves in with a series of questions to pin down the nature of the pain, its time course, frequency, duration, pattern of radiation, and its exacerbating and ameliorating factors. Patients use language to express the sensations of things being amiss. They, by definition, don't know what is the matter; hence their visit to the doctor. Their goal in linguistic performance is to express all facts, feelings, fears, and past events that may relate to the sensation. Because patients don't know how (or in what) to contain the sensation, they use language to express multiple levels of knowledge: thoughts, feelings, descriptions, associations , metaphors, guesses about causality, and reports of their...