209
What even is the medical case? Always, historians of medicine, clinicians, classicists will point to the seven books of the Hippocratic Epidemics. But for the most part, Hippocratic cases are sparse chronologies of symptoms, with little in the way of treatment or presence of a ‘clinical’ actor or even narrator. They chart a progression through time of a certain instance of disease. But a disease with no name, no analysis, no therapies and – more often than not – no survival for the patient. These cases are observations of declines (or recoveries) that are, if not exactly mysterious to the almost invisible recording eye, certainly opaque. They are not cases of anything, except of being a patient, of being mortal, of being human. If they build an evidential base, a collection of data, it is only in support of that great truth: we sicken, we die. As for meaning, they mean that the healer is the one who watches, who searches for meaning as a form of patterning, of a responsive relationship between the progression of decline (with its recoveries and relapses) and the humoral conception of the body and the environmental ‘constitutions’ that accompany these cases.
To consider the medical case in contemporary orthodox medicine – the professionalised, techno-scientific practice of the past 200 years – is to raise a profound question about the status of evidence. On the pyramid hierarchy of evidence, adopted and formalised through medical training and assessment criteria like GRADE, the individual medical case is commonly the lowest level, with the case series afforded slightly more value. Each individual case stands as a singularity, which may, within the context of series (formalised or not) gain evidential weight. It may come to mean beyond what it is, or what it tells. The most potent instances of this is in the emergence of a new disease or syndrome. Individual cases, that appear as atomised anecdotes, start to cohere. They are no longer cases. They are cases of. They become evidence retrospectively. Consider how cases of a susceptibility to Kaposi’s sarcoma and cases of a community-based outbreak of pneumocystis carinii pneumonia came to be cases of HIV/Aids.
But some cases never become cases of. Perhaps they are so peculiar in their singularity, and are recorded for their novelty. Perhaps there is ultimately no recognisable underlying pathology. There is no meaning that can be given to them, at least, no clinical or diagnostic meaning. Why then are they published or circulated? They become in these instances evidence of something else. Not a disease or a syndrome, but evidence of the clinician. Of their humanity, of their concern, of their urge to heal, of their compassionate witnessing, of their powers of observation, of their learning, of their professional and monetary worth. perhaps only of the diffuse presence of some kind of invisible entity: medicine.
For everything that clinical medicine touches has to be a case, but the relationship between medicine and the case is one of power. The case is a power statement. In declaring something to be a case – even if it is a never a case of – medicine re-affirms its own status. Cases comprise a membrane binding and giving form to that which lays claim to the status of medicine. They are evidence of medicine, but only as a surface effect, as the immaculate palace is evidence of the strength of the state, or the sounding of the oath is evidence of the truthfulness of the witness, or the face is evidence of the intelligence behind it.
To accept the case as evidence of medicine’s authority is to be complicit in the performance of the surface effect. It is to accept the wizard as self-evident evidence that he is indeed wonderful.
Back to the Index