Remaking the Case

Narrative persists in medicine, as it does in the human sciences generally, as both a source of information and a means of organizing its interpretation. Unscientific though narrative may seem, the case is not only a record of medical attention provided a patient, but the fun- damental unit of medical discourse and the pattern for clinical reasoning. With its hypothetical, testable, diagnostic plot, it enables the physician to apply the nomothetic principles of biomedical science to the patient's idiographic manifestations of illness.1 Like thinkers in other fields that rely on cases—law, moral theology, criminal detection—physicians rea- son backward from effect to cause by constructing from the signs (or clues, facts, evidence) a probable narrative whose validity can be tested by further interrogation of the phenomena. Neither so satisfyingly co- herent as fictional narrative nor so epistemologically secure as the repli- cable demonstration of scientific fact, the medical case lies somewhere between the two. It is, in short, history. As a working part of the process of diagnosing and treating disease, the case aspires to scientific rigor. But the epistemological shift that in the late twentieth century has called into question the simple, objective, logical-positivist view of knowl- edge—medicine's working epistemology—has affected the way we think about case history, too. No longer taking the Newtonian physical sci- ences as the sole pattern of rationality, thinkers have turned in recent years to the contextual, interpretive methods of knowing that are char- acteristic of the social sciences and the humanities. Narrative is one of the chief of these. Not surprisingly, then, recent changes in the case