The Medical Imagination

The Medical Imagination traces the practice of using imagination and literature to craft, test, and implement theories of health in eighteenth- and nineteenth-century America. This history of imaginative experimentation provides a usable past for conversations about the role of the humanities in health research and practice today.

The Medical Imagination
Literature and Health in the Early United States

Sari Altschuler

Feb 2018 | 360 pages | Cloth $55.00
Literature | American History | Medicine
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Table of Contents

Introduction
Chapter 1. Revolution
Chapter 2. Yellow Fever
Chapter 3. Cholera
Chapter 4. Difference
Chapter 5. Anesthesia
Conclusion. Humanistic Inquiry in Medicine, Then and Now

Notes
Bibliography
Index
Acknowledgments


Excerpt [uncorrected, not for citation]

Introduction

EXPER'IMENT, Experimen'tum; same etymon. (F.) Expérience. A trial, made on the bodies of men or animals, for the purpose of detecting the effect of a remedy, or of becoming better acquainted with their structure, functions, or peculiarities. In a more general sense, it means any trial instituted with the intent of becoming better acquainted with any thing.
—Robley Dunglison ("The Father of American Physiology"), Medical Lexicon (1839)
In the fall of 1841, physician and novelist Dr. Robert Montgomery Bird (1806-1854) stood before a group of new medical students and delivered what must have been a dispiriting talk. In The Difficulties of Medical Science, Bird explained that medicine faced many challenges. Every science, he told his students, was, "and of a necessity must be, imperfect," but the difficulties of medicine were "greater and more numerous." It was hard to reproduce results, for example. It was impossible to observe healthy, functioning organs. The senses were imperfect, and human bodies were incommensurably unique. "It is physically impossible," Bird stressed, to "know many things it would delight Medicine to know." Bird was committed to medicine, whose "whole object" was to benefit humanity and to reduce suffering, but he worried about the immense physical and ethical impediments to medical research. "How shall we detect the workings of the invisible and intangible enemies around us?" he asked. "How shall we trace the mechanism of a disease? how shall we follow even the operation of a remedy, through the darkness of a microcosm of which we are so ignorant?" "We have no window of Momus," Bird lamented, "to give us vistas of living pathology."

Invoking Momus, the classical figure who teased Hephaestus for making the body without a window through which to see the human heart, Bird offered a humanist's alternative to the insufficiencies of medical observation and physical experimentation. Doctors and surgeons had difficulty safely or ethically opening up the living human body—especially before the development of anesthesia and germ theory. Unable to see physiology or "living pathology," doctors could observe little about how the body worked. Momus was the god of satire, whom Laurence Sterne called the "arch-critick." In conjuring Momus, Bird not only invited his students to integrate classical learning into their understanding of medicine (not unusual in a time when classical education was necessary for the serious study of medicine) but also asked his students to think critically and creatively about the tools at their disposal for medical inquiry.

Throughout his life as in his lecture, Bird's literary and medical interests intersected. He used the classics, quoted verse, and invoked Shakespeare in his medical writings. He wrote poetry while he studied medicine, and his extant medical notes can be found on the backs and in the margins of history, drama, and fiction manuscripts. Bird likely found pleasure scribbling his lecture on "artificial stimulants" on the back of a diatribe against American business practices from one of his novels and medication notes on the back of a page about race and immigration. The repeated proximity of these projects—fiction and medicine, often on the same pages—suggests Bird was working on them simultaneously and that they informed each other (Figure 1).

It may have been physically impossible to know certain aspects of health, but, like many doctors of his era, Bird also used imagination and literary form to explore challenging questions in medicine. Bird was a physician who understood that genres were strategies; their different forms allowed writers to examine different facets of health. This was especially true in his novels. He used fiction to investigate aspects of health that were difficult—if not "impossible"—to test physically, as well as those that were better pursued through humanistic methods. Like the eponymous narrator of his 1836 novel Sheppard Lee: Written by Himself, Bird hoped readers would "have a more liberal understanding of the subjects of knowledge."

Robert Montgomery Bird offers a particularly illuminating, but by no means unique, window onto the medical work of literature; in fact, medicine and literature had a long, entangled history in the Atlantic world. Richard Blackmore (1655-1729), Samuel Garth (1661-1719), John Armstrong (1709-1779), Mark Akenside (1721-1770), and John Keats (1795-1821) were just some of Britain's notable physician-poets during the eighteenth and early nineteenth centuries, and doctors like Tobias Smollett (1721-1771) and Oliver Goldsmith (1730-1774) composed in other literary genres. In the Caribbean, men like James Grainger (1721-1766) wrote medical poems and sent them back to the metropole, hoping to make their fame. Even prominent physicians who were not well-known for their poetic aspirations, like vaccine inventor Edward Jenner (1749-1823), penned verse that circulated in both literary and medical contexts. In this period of classical revival, doctors fashioned themselves after Apollo, god of both medicine and poetry. Physician-writers were not anomalies but rather actors engaging in a long and robust tradition of literature and medicine.

Founding Father and famed physician Benjamin Rush (1746-1813), the most famous American doctor for nearly a century, explained why: "Exactly the same thing takes place in the act of judgment in selecting and combining related ideas and rejecting such as are not related, as takes place in selecting and combining words, in writing poetry and rhyme. The ear combines related words, or such as—to use a common phrase—do not jangle with each other; and rejects such as are not related." With practice, this cognitive process came to seem natural rather than nurtured, but Rush pressed his students not to be deceived: good medical thinking was the product of a well-trained mind, and poetry was an excellent tool for developing one. Poetry also helped train the perceptions that made judgment possible. Given the value Rush placed on poetry, it is not surprising that he also made "frequent recurrences to the poets" in his medical writing because they viewed phenomena, "whether natural or morbid, with a microscopic eye, and hence many things arrest their attention, which escape the notice of physicians." In describing poetic vision as a "microscopic eye," Rush radically repurposed a phrase that had a long European genealogy to describe the valuable role poetry ought to play in producing medical knowledge. Whereas eighteenth-century writers like Alexander Pope (1688-1744) claimed no one had a microscopic eye (it would be painful and dangerous, he argued), Rush celebrated this faculty. In Rush's view, poetry was creative and exacting—essential for mastering the kind of thought and perception that lay at the heart of good medical practice and discovery.

From the earliest days of medicine in the United States doctors turned heroic couplets toward the ends of heroic medicine. Samuel Latham Mitchill (1764-1831) used poetry in 1797 to make his case about the geography of human health, as did Joseph Young when he quoted Alexander Pope's verse in the pages of the New York journal the Medical Repository to defend the use of analogy in place of observation in science. A North Carolinian student of Rush, Charles Caldwell (1772-1853), urged doctors to be poetic and imaginative in their medicine in 1797, hoping they would follow the example of British physician-poet Erasmus Darwin and combine "the researches and decisions of the understanding, with the sportings [sic] and flights of imagination." A physician-poet himself, Caldwell believed it would not be long before an American Darwin emerged: "From the rapid and general diffusion of physical science throughout our country, and from the growing taste for the beauties of literature acquiring such depth of root in the American mind," he wrote, "we are . . . encouraged to flatter ourselves, that [the arrival of such a figure] is not deeply buried in the ever-teeming matrix of time." Emphasizing Darwin's history as a country doctor, Caldwell pushed his counterparts in the United States to consider the physician-poet path for themselves.

In the late eighteenth and early nineteenth centuries, doctors wrote poetry that was formally strict; constrained meter and rhyme organized their theories and observations. Ordered poetic form kept a tight rein on doctors' imaginations. Although doctors' poetry filled the pages of American journals and magazines well into the nineteenth century, their work has gone largely unnoticed because much of the verse—highly structured and widely practiced as it was—has seemed uninteresting to a more modern eye. Its form was, however, largely the point, and the practice of writing this kind of poetry was valuable training for the medical mind.

Writers outside the medical establishment also found literary forms valuable for producing medical knowledge. In the 1790s Charles Brockden Brown experimented with the potentially fatal "force of imagination" in his novel Ormond, just as he understood his fictional story Arthur Mervyn "methodize[d] reflections" that contributed to "medical and political discussions . . . now afloat in the community." Likewise, Bird's contemporary Edgar Allan Poe penned "prescient descriptions" in short stories that were celebrated in elite medical journals from JAMA to the Lancet. The prevalence of nineteenth-century doctor-writers—not only Bird but also Martin Robison Delany, William Arthur Caruthers, Oliver Wendell Holmes, and Silas Weir Mitchell, to name a few—should not surprise us. Nor should the prevalence of other doctors like Thomas Chivers, John Kearsley Mitchell, and Samuel George Morton, who wrote literature. Cultural critics and medical researchers have repeatedly marveled at the serendipitous instances in which "fiction anticipates science" rather than understanding fiction could produce it. Recognizing how much medical work literature did in the early United States reframes our understanding of both medical and literary history.

Humanistic Inquiry and the History of Medicine

Why has this tradition been so difficult to see? The first answer lies in the history of American medicine as a field of inquiry. Originally it was a remarkably presentist field, invested in the past only insofar as it revealed important figures, milestones, and breakthroughs for medical science from a contemporary perspective. This meant that historians of medicine were not so much interested in understanding how medicine worked in earlier periods as they were in how the past contributed to medical success measured in contemporary terms. Beginning with the turn toward a social history of medicine around 1980, historians of medicine adopted a more capacious understanding of health to great effect, opening the door to fields including demography, anthropology, sociology, linguistics, and historical epidemiology but, notably, not to literature. Historians of American medicine are still working to move beyond a version of the field that principally uses empirical methods to study the rise of empiricism.

The problem with an over-investment in empiricism-oriented history is that medicine was not an exclusively empirical enterprise in the early United States—far from it. In fact, although this period is often described as marking the shift from rationalism to empiricism, the epistemological conflicts in medicine that took place in these years tell a more complicated story. A simple narrative of the period might suggest that traditional medicine through the early 1820s depended on rationalism, a high-minded, philosophical approach to medicine. In its preference for simplicity, rationalism supported "heroic" treatments that led doctors like Rush to irresponsibly blister and bleed patients sometimes to death. In the first decades of the nineteenth century, the story continues, the ineffectiveness of these methods gave rise to a pluralistic medical culture in which alternative practices rivaled traditional medicine. Even traditional physicians grew sick of rationalism by the 1830s and turned to French and German medicine to become empiricists—doctors trained in clinical observation and scientific experimentation—a move that began the path toward modern medicine. Insofar as this history highlights the degree to which ineffectual physicians in the United States relied on European intellectual work and innovation, it depicts the first century of American medicine as derivative, an indictment American literature scholars of the period will recognize from their own past.

When we adopt a dismissive tone in describing early U.S. medicine, we uncritically accept medical histories that originated with fin-de-siècle physicians who were hoping to bolster their own precarious authority by denigrating the profession's recent past. Abraham Flexner epitomized this attitude in his Medical Education in the United States and Canada (1910), a report that revolutionized medical schooling in the early twentieth century by insisting on empiricism. The promise of early medical schools, he writes, "was not long maintained. Their scholarly ideals were soon compromised and then forgotten" in corrupt institutions, replaced by "exaggeration, misstatement, and half-truths." Occasionally, "of course, the voice of protest was heard, but it was for years a voice crying in the wilderness."

However, the medical history of the early United States is far more complicated and interesting than an empiricism-oriented history can reveal. A first step toward seeing this history is to remember that the transition from rationalism to empiricism took decades and that the terms of these epistemologies remained unstable throughout the period. The medical word "rational" could mean anything from "common sense" to a deductive philosophical approach or a practice that partook of a professional exclusivity and was overly concerned with rules. Likewise, "empirical" could be used to name objective experimental practices, "mechanical, indiscriminate practice," or professional ignorance, as the related and derogatory term "empiric" implied.

More important, focusing exclusively on rationalism and empiricism cannot account for a crucial third term nineteenth-century doctors and writers used to understand human health: imagination. Rationalism may have declined uncertainly over the first half of the nineteenth century, but both rationalists and empiricists continued to insist on the epistemological value of the imagination. Nevertheless, it is because early American doctors spoke of tears and horror that they have been seen, retrospectively, as amateurs, and it is because they wrote in diverse genres that they have not been seen as committed professionals. This formal flexibility, however, defined American medical thought, and it is precisely because doctors and writers were able to speak in multiple registers and occupy multiple roles that their original thoughts about human life and health circulated freely and effectively. Rather than be surprised by the number of American doctor-writers, we ought to understand that the prevalence of such individuals reveals the epistemological and discursive structure of American medicine in which philosophy, literature, and physical experimentation were not incompatible approaches but rather a diverse, adaptive, and adaptable tool kit for medical knowing. We have had trouble doing so because these ways of knowing from the recent past are so different from our own.

In fact, humanistic training was a part of the ideal medical education in the long nineteenth century. The first medical school in the United States, the University of Pennsylvania, began offering training only to those who already demonstrated competencies in math, Latin, and natural and experimental philosophy. Since most medical literature, including theses, was written in Latin, proficiency in the classics was considered essential to a successful career. Medical leaders in New England reaffirmed this commitment when they met in Northampton, Massachusetts, in 1827 to discuss the future of medical education. They recommended that, beginning in 1829, every student should have "in addition to a good English education, a sufficient knowledge of the Latin language to read the Aeneid of Virgil and the select orations of Cicero, [and] to have a good acquaintance with geometry and natural philosophy." Ten years later, Joseph Eve, a South Carolina-born physician, agreed, seconding the recommendations of the Medical College of Georgia that the "most varied and extensive learning is required in a physician. . . . Next to the vernacular tongue, the Latin and Greek languages are most important as preliminary to the study of medicine" and that "a knowledge of these languages is of incalculable value to the student, and can not be dispensed with but at the expense of one or two additional years of hard study." While it was not always possible to enforce such prerequisites, Americans remained committed to a vision of medical training with this humanistic standard at its core, and medical schools would not fully break with it until early in the twentieth century.

Imaginative Experimentation

In this pluralistic world of medical epistemology, doctors and writers used their imagination and literary tools to produce medical knowledge, a practice I am calling imaginative experimentation. The term "imaginative experimentation" describes both the various ways in which doctors and writers used their imaginations to craft, test, and implement their theories of health and the role literary forms played in developing that work. My use of the word "experiment" here retains Robley Dunglison's "more general sense" of "any trial instituted with the intent of becoming better acquainted with any thing." This sense is particularly useful in moments where imaginative experiments provided new avenues for medical knowledge. While some imaginative experiments influenced a number of doctor-writers to come, others had only a single instantiation. I have worried less about whether certain imaginative experiments were repeated or repeatable and instead worked to demonstrate the creativity and ingenuity of particular attempts—experiments in the broader sense of the word.

Rationalists and empiricists alike privileged this role for the imagination throughout the long nineteenth century. As Dunglison wrote in his 1832 textbook Human Physiology, "It is to the capability of indulging to the necessary extent in [a] kind of mental abstraction, that we are indebted for the solution of every abstruse problem, relating to science or art." Later in the century, avowed empiricist S. Weir Mitchell also privileged imaginative experimentation. A champion of vivisection and microscopy and a doctor-novelist, Mitchell explained that "there are times when, starting from facts, imagination is on the wing. It casts its treasure at the feet of reason." He pictured his "poetic imagination" as "a wild-winged thing" that formed an important part of medical and scientific discovery: "the wild flight after the [empirical] proving . . . may be hopeless," he wrote, "but seen with the eye of imagination the page reads clear." Mitchell called this use of the imagination "science on the wing." When a friend wrote to ask whether science and the imagination were at odds, Mitchell replied: "'Science and imagination at war'? Why? The latter is the very soul of the former."

For doctors like Rush, Bird, and Mitchell the imagination was fundamental to medical and scientific work. The medical imagination was not for them a tool of last resort only to be used when other methods of discovery had failed, although it was certainly useful then, too; rather, imaginative experimentation formed part of a more flexible and dynamic complex of knowing. Imagination worked with other epistemological tools including observation, physical experimentation, philosophy, and history toward the ends of discovery. In this less disciplinarily regimented time, epistemological flexibility allowed doctors and writers to work through thorny medical complexities, and the imagination assisted practices like observation and physical experimentation that alone could only partly explain health.

Using the imagination in medicine was a less foreign concept for eighteenth- and nineteenth-century Americans than it is for us today, since, until at least the mid-nineteenth century, medical knowledge was understood to be formed in the mind of the brilliant observer—not through depersonalized, objective observation. In 1798, Johann Wolfgang von Goethe expressed the perspective thus: "to depict [pure phenomena], the human mind must fix the empirically variable, exclude the accidental, eliminate the impure, unravel the tangled, discover the unknown." For doctors, "experiment" was related to the French word expérience, which capaciously suggests both "experiment" and "experience," and, through at least the 1830s, the medical definition for "experience" came from the root word "'to practise.' A knowledge of things, acquired by practice." The meaning of the word would continue to develop over the course of the nineteenth century, but as early as 1848, Dunglison marked the shift toward objectivity in a revised definition: "expe'rience, [from the Greek for] 'a trial.' A knowledge of things acquired by observation." Here Dunglison moves the site of knowledge production from the more intimate involvement with the knower (suggested by "practice") to the detached position (suggested by "observation"). Nonetheless, through at least 1860, the definition retained the primacy of the mind as a site of knowledge production: "To profit by experience," Dunglison writes, "requires a mind capable of appreciating the proper relations between cause and effect." Before the mid-nineteenth century, knowledge came from an intelligent knower who used trained mental faculties to construct truth from imperfect perceptions. "Only in the mid-nineteenth century," Lorraine Daston and Peter Galison write, "did scientists begin to yearn for this blind sight, the 'objective view,'" that is, "seeing without interference, interpretation, or intelligence." Even this emerging perspective continued to be contested throughout the early twentieth century.

Especially before the mid-nineteenth century, an important strain of medical research depended more on the mind and body of the individual investigator than on an objective detachment. Of physicians' nonobjective practice of experimenting on their own bodies, for example, Bird wrote that doctors daily "peril life and health in the performance of such experiments" because the "moral code of medicine calls upon [physicians] to encounter the first danger themselves." Methods that used doctors' bodies and minds made sense to writers like Bird both because they freed medical research from a number of ethical quandaries and because they brought experiments closer to the physician's observation and judgment. For thinkers like Bird and Rush, doctors and writers possessed "epistemologically weighty" bodies and minds that offered more valuable information than that provided by other experimental subjects because their trained perceptions were deemed more reliable.

This emphasis on privileged minds, along with the privileged role of the imagination in the period, granted authority to the imaginative experiments. The imagination was a particularly fertile site for this kind of experimentation not only because of the centrality of the imagination to the highest orders of thought but also because the imagination was linked directly to somatic health in the eighteenth century. In the 1720s, for instance, England was captivated by the story of Mary Toft, who claimed, after a memorable dream, to fall ill and some months later to give birth to a "monstrous" creature and a series of rabbits. Erasmus Darwin countered this idea by declaring "that the world has been long mistaken in ascribing great power to the imagination of the female," whereas it was really the father's imagination that shaped the fetus. Scottish medical philosopher William Cullen believed that "a number of people can . . . by the power of their own imagination, throw themselves into a real epileptic fit" and told the story of a woman who developed such troubling associations with a gown that seeing one brought on "sickness and vomiting." Edinburgh's Robert Whytt and London's William Rowley firmly avowed the mental causes of fainting and convulsions. On the American side, Benjamin Rush connected the imagination to fever in Medical Inquiries and Observations Upon the Diseases of the Mind by recalling a story told by Lucian in which a tragedy performed midsummer in Abdera greatly exacerbated a fever outbreak, "produc[ing], very naturally, a repetition of the ideas and sounds that excited their disease." Throughout the nineteenth century Americans continued to believe that imaginative enterprises like literature produced somatic effects. Since the imagination and the health of the human body were intimately linked, experimenting imaginatively provided an avenue through which Americans could both theorize and promote health.

Genre was the grammar of this experimentation. Literary genres were excellent forms for exploring theories of the body. Poetry helped doctors experiment at scales—from the minute to the global—that they could not observe directly or test physically, and formally rigorous poetry allowed physicians to explore medical questions imaginatively using creative and ordered intellectual thought. Fiction allowed thinkers to test medical phenomena that would have been unethical to explore physically and also to work through complex problems without committing to a particular solution. Novelistic forays into the lives of others permitted doctors to examine experiences beyond what their individual embodiment would have otherwise allowed. And the picaresque allowed doctors and writers to investigate a variety of loosely connected situations and embodiments to understand problems in health from a broader variety of perspectives. Imaginative literary forms, in turn, also promoted health insofar as genres like satire, sentimentalism, and the gothic shaped the moral, emotional, intellectual, and physiological constitutions of readers. These were only some of the reasons why doctors and writers used literary form to experiment with health in the early United States, but they suggest the array of advantages imaginative experiments offered for pursuing medical questions.

Physiology and the Problems of Medical Knowing

Imaginative experimentation was a widespread practice that was especially useful in health fields like physiology where empirical knowing could be quite difficult. Physiology, which referred broadly to the functioning of living organisms, has long been harder to capture than its sometime twin, anatomy. The history of anatomy fits well within narratives of rising empiricism. Our accounts of the nineteenth century are full of dissections in which the secrets of the human body were laid bare to the naked eyes of curious physicians. And yet, in the nineteenth century, anatomy was mostly important for what it could reveal about physiology—people were less interested in dead bodies in and of themselves than in what they might reveal about the dynamic workings of the live human body. As a popular early nineteenth-century textbook explained, physiology was "the science of life" while anatomy was merely "the science of organization." These definitions remained relatively stable throughout the period. In 1861, Oliver Wendell Holmes rephrased them thus: "Anatomy studies the organism in space. Physiology studies it also in time." In 1856, Robley Dunglison wrote of the importance of physiology in his textbook on the subject, "There is no department, perhaps, of medicine, to which the attention of so many investigators has been, and is, directed as to that of physiology." (Dunglison opened the first volume of that textbook with nine lines from Milton.)

Physiology was vitally important for understanding human health, but learning about it was notoriously tricky business. At a practical level, understanding how the healthy, living body worked through direct observation and physical experimentation was all but impossible. Even though doctors were surrounded by healthy bodies all day every day, they had very little experience with their workings either on the outside or on the inside. Medical consultations rarely came with the kind of physical examination we consider routine today. Such exams were highly unorthodox and potentially offensive. Patients came to doctors to describe their medical complaints, not to disrobe. Whereas the prohibitions around knowing the healthy body from the outside were most often ethical, the limitations to knowing the healthy body from the inside were both ethical and practical: the vivisection of living humans was unspeakable, and, in any case, the first cut into healthy flesh rendered it unhealthy.

Physiology was also hard to know because it depended on an idea of a body in constant motion. The body was always moving, adapting, reacting, and changing. While Benjamin Rush's now well-worn sentence aligning men with "Republican machines" has come to stand in for how many scholars explain understandings of the body in the early United States, doctors like Rush did not hold a mechanistic view of the human body. Instead, they worked to know the body as an ever shifting, pushing, pulsing thing that was deeply and dynamically engaged in the work of living.

Circulation provides a useful example of this dynamism and of the difficulties involved in trying to understand healthy physiology through physical investigation. Posthumous anatomical dissection could only offer so much to the researcher interested in the dynamic work of healthy circulation. Nor could the highly fraught practice of vivisection, which gained momentum in the mid-nineteenth century, offer a complete picture of the circulation in the healthy body—even if cutting open a living human body to see how the heart worked could somehow be ethically performed. The limitations of ocular knowledge were also registered in the use of the pulse to determine health (tactile knowledge) and the development of the stethoscope (auditory knowledge). This proliferation of approaches to knowledge production suggests that none of them was completely satisfying.

Physiology posed further challenges to medical knowing because its keywords were also social and political concepts. This was no accident: the period's rationalist physicians prized unitary systems that explained how the world worked at a variety of levels. Healthy American bodies comprised the healthy body politic, and, as such, the body served as a metonym (rather than a metaphor) for social and political life. Nevertheless, the various entanglements of terms like "circulation" and "sympathy" made theories of the body much weightier and more difficult, especially for empiricism. Circulation was a concept that extended from blood vessels to global networks of exchange, and sympathy cohered both bodies and nations.

Imaginative experimentation was, thus, especially useful for fields like physiology when physical means of knowing were limited, but it was also an invaluable mode of inquiry in its own right. Observation and physical experimentation could tell medicine only so much about the human body. Even if a window of Momus were able to reveal its healthy inner workings, many eighteenth- and nineteenth-century doctors and writers believed their imaginations would still be needed to convert that observation into discovery. Imaginative experimentation was an important tool of inquiry that helped doctors and writers explore what could not be seen, draw novel conclusions from observation and experiment, and understand aspects of health that exceeded mechanistic paradigms.

Epistemic Crises

I have organized the book around a series of moments I am calling epistemic crises. During these crises, a central precipitating event, such as an untreatable epidemic disease, a significant discovery, or a political crisis, unseats central ideas about the health of the human body. In these moments, problems of knowledge and epistemology come into relief. The epistemic crises of the period between the revolution and the Civil War—from yellow fever and cholera to the American Revolution and the discovery of anesthesia—are particularly rich for opening up the tools of knowledge production and viewing the nineteenth-century complex of knowing: they reveal both the limitations of epistemologies such as objectivity and empiricism alone and the work of imaginative experimentation. Especially at these moments when core understandings of human health were fundamentally destabilized, doctors and writers used their imaginations to experiment with new strategies for knowing and to investigate new solutions. This book is thus organized by a series of epistemic crises that upended commonly held beliefs about human health and demanded new ways of thinking.

My thinking about epistemic crisis is indebted to a long history of conversations in science studies about the history and shape of scientific knowledge. Central to the work of key figures in this field, from Ludwik Fleck to Bruno Latour, is the idea that scientific thought is collectively produced and that particular ways of thinking—variously called thought styles, paradigms, or epistemes—dominate particular periods. While theorists like Fleck and Michel Foucault spend more analytical energy on the modes of thinking themselves, scholars like Latour and Thomas Kuhn are more attentive to the processes through which certain ways of thinking come to dominate scientific thought. For Kuhn, these moments of "paradigm shift" are prompted by "crises," in which major discoveries unsettle foundational premises of scientific thinking or anomalies appear that last "so long and penetrate so deep that one can appropriately describe the fields affected by [them] as in a state of growing crisis." Such crises are, according to Kuhn, "a necessary precondition for the emergence of novel theories." They attend both recognized scientific revolutions and "many other episodes that [are] not so obviously revolutionary." Following Kuhn, philosopher Alasdair MacIntyre clarifies that such episodes are "epistemological crises" but takes issue with Kuhn's notion of crisis as a complete break with the past. Instead, MacIntyre emphasizes that moments of crisis are necessarily linked to the worldviews that dominate before and after, and that the resolution of a crisis thus always involves a new perspective that better explains both the crisis and the paradigm that preceded it.

My term "epistemic crisis" draws on this intellectual lineage, but it also departs by focusing on medical rather than scientific knowledge. For Kuhn and other theorists of physical science, crises are either the result of discovery or the building up of anomalies. These processes of epistemic change in fields like Kuhn's home discipline, physics, are necessarily different from those in medicine in which external forces like epidemics prompt crises with more force and immediacy. The social, cultural, religious, and political imminence of crises in medicine is distinct from crises in the physical sciences. Laypeople are well aware when a pandemic arrives; nonhuman agents like microbes demand immediate explanation and action. In the cases of crisis-causing diseases like yellow fever and cholera, physicians' epistemological failures registered quickly in the broader community. Competing accounts emerge not only from within medicine but also from a variety of other sources from lay practitioners to the clergy that shape and contest physician authority. More generally, because medicine is structurally interpersonal (centered around encounters between doctors and patients), because medical issues like pain and disease affect all human bodies, and because medical knowledge is intimately bound up with fundamental issues of ethics, medicine's ways of knowing are necessarily more public and subject to a wider variety of forces than paradigms in fields like physics and chemistry. Epistemic crises in medicine are both more pressing and more complex.

I have also adopted this language of "crisis" throughout for historical reasons. Crisis was a key concept in nineteenth-century medicine. According to Noah Webster, the primary definition of crisis was medical: "1. In medical science, the change of a disease which indicates its event; that change which indicates recovery or death." The second definition preserved the sense of an eventful alteration that either heals or destroys but framed it more broadly as "2. The decisive state of things, or the point of time when an affair is arrived to its highth [sic] and must soon terminate or suffer material change." Crisis writ more broadly names a period after which a system—in this case a system of ideas—would adapt or end. Medical definitions of the period explicitly privilege the role of the mind in crisis. As with "experiment" and "experience," Dunglison's original definition of medical "crisis" privileges the knower, coming from "Diacrisis, Judgment; from krinō, 'I judge,'" whereas by 1848, he limits the word to a more objective sense, "Diac'risis, Dijudica'tio, 'decision'" and "krinō, 'I decide.'"

Epistemic crises are imaginatively rich. Kuhn describes crises in science as necessarily creative: "Like artists, creative scientists must occasionally be able to live in a world out of joint—elsewhere I have described that necessity as 'the essential tension' implicit in scientific research." MacIntyre likewise turns toward creativity in crisis, using literary examples—Shakespeare's Hamlet and Jane Austen's Emma—to explain epistemological crises as fundamentally narrative. During the more prolonged epistemic crises of this book we can more clearly see this experimental and imaginative work.

The chronological moments of crisis in the chapters that follow do not cumulatively narrate an unwavering forward march of medical progress. Instead, they demonstrate that, while breakthroughs undoubtedly occurred during the period, new ways of medical knowing were always also the product of their historical context, specific to times and places in which such inquiry took place. What accretes over the course of the book, then, is not a story of medical heroism and advancement but an account of the varied epistemological uses of imagination and literary form to produce medical knowledge, especially but not exclusively in moments where physical experimentation proved insufficient for medical knowing. Although they were not the only moments in which doctors and writers turned to their imaginations to investigate medicine's mysteries, epistemic crises are useful flashpoints that illuminate a broader practice; they are useful for framing the work of imaginative experimentation.

The crises that organize this book fall into three categories: political crises, crises of disease, and crises of discovery. Chapters 1 and 4 treat crises in which medical and political events conspired to challenge the fundamental premises of human health. Chapter 1 tells the story of how, in the wake of the revolution, Americans were forced to seek out new republican models of health to replace the monarchical ones they had brought from Europe. Chapter 4 explores how emergent ideas about issues including race, sex, region, and species fractured those unitary republican models, necessitating new investigations into the nature of human difference. Chapters 2 and 3 treat disease crises in which the arrival of epidemic diseases revealed the ineffectiveness of particular medical paradigms through spectacular failures in treatment (Figure 2). Chapter 2 tracks how, when yellow fever returned to the eastern seaboard in the 1790s after decades of reprieve, it forced doctors to reimagine fundamental ways of understanding medical communication. Chapter 3 argues that when in 1832 cholera appeared for the first time ever in the Americas, it fundamentally reframed notions of medical geography. The last chapter of the book explores the crisis of discovery set in motion by the development of anesthesia, in which the sudden availability of a state without feeling forced Americans to reevaluate the nature and value of pain.

Just as these crises were distinct in their nature, effects, and temporalities, each also had its own geographic scope. The 1790s yellow fever pandemic, for example, was an Atlantic event, but in the United States it registered as a series of locally shocking outbreaks in Philadelphia and New York that told a national story. The "Asiatic" cholera outbreak in 1832, on the other hand, was understood by many as a truly global crisis that had traveled from India through Russia into and across Europe and finally through Canada and into the United States. Conversations about American health crises were intimately bound up in the ideas and events occurring around the Atlantic, but, during the first century of U.S. medicine, Americans most often understood health in national terms because of close connections they imagined between corporeal and political systems. In this book about ways of knowing, I have relied largely on the actors' own understandings of their work, which were usually, although not always, national—even if today we understand events like the yellow fever epidemics and cholera pandemics as irreducibly transnational. This transnational perspective does surface at times—especially in the 1850s work of figures like Martin Robison Delany and Baron Ludwig von Reizenstein—but it is largely the exception not the rule. And even as the national scale emerges as the most commonly used for the project of American health, I have worked to situate the discussions of each chapter in their local and transnational contexts as well.

Finally, neither the epistemic crises I describe nor the imaginative practices used to understand them were limited to the period explored here. Just as this book offers a U.S. history in an Atlantic (and at times global) context, it understands medicine and literature in the context of a broader history of humanistic work in medicine. The period covered by this book extends from the American Revolution to the Civil War, and yet this history of imaginative experimentation grew out of eighteenth-century Atlantic practices and continued for decades after the Civil War. I focus on the period roughly between 1775 and 1866, however, because it was a particularly vibrant moment for using the imagination and literary form to understand crises in medicine. This introduction and the conclusion suggest the longer history of imaginative experimentation, especially as it grew more difficult to practice in the late nineteenth century. Perhaps unexpectedly, it was precisely because the professionalizing forces of the Progressive era were making humanistic inquiry in medicine more difficult that doctors and writers were much more vocal and explicit about its value for medicine during those decades. It was not until the early twentieth century that medical education was systematically reorganized to exclude humanistic thinking from medical work—and even then, prominent medical researchers continued to insist on the importance of a medical imagination.

Past, Present, Future

At its most ambitious, this book aims to reframe our understanding of the relationship between literature, medicine, and the imagination in the first century of the United States and the relationship between health and the humanities today. Moving beyond the idea that literature simply reflected medical ideas of the period, The Medical Imagination argues that the imagination and literary form robustly contributed to medical knowledge, offering important epistemological tools for knowing health in the early United States. I argue that literature allowed eighteenth- and nineteenth-century doctors to assay medical hypotheses that were difficult to test otherwise for physical or ethical reasons, to augment knowledge acquired through observation and experience, to investigate that knowledge, and to transform data into discovery. This work builds on that of Rita Charon, Cristobal Silva, and Priscilla Wald, who powerfully demonstrate medicine's narrative structure, as well as that of Russ Castronovo, Justine Murison, Jane Thrailkill, and Bryan Waterman, who compellingly show how medical models shaped the period's literature, to analyze a discursively permeable past in which doctors and writers used poetry, fiction, and other literary forms to produce original medical knowledge, especially when medical philosophy and physical experimentation failed to produce satisfying results. The Medical Imagination fuses these strands of inquiry to describe a world in which doctors wrote medicine in literary genres and literature proposed medical theory. In other words, this book aims to expand our understanding of literature's cultural work beyond the social and the political to the medical. In so doing, The Medical Imagination's recovered history not only demonstrates literature's central role in knowing health in the eighteenth and nineteenth centuries but also illuminates promising new avenues for medical and scientific education, research, and practice today.

It is my hope that the argument this book makes about the past will help us reimagine the role of the humanities in medicine and the health professions in the present and future by sharpening our articulations and expanding our vision. In recent years the medical humanities have provided an important set of responses to pressing issues in contemporary medicine. Concerned about a field of medicine driven more by routinized procedure and the bottom line than more complete sense of patient care, medical humanists have founded physician reading groups and added courses to medical curricula countrywide. Medical humanities programs insist that "the humanities and arts [can] provide insight into the human condition, suffering, personhood, our responsibility to each other, and offer a historical perspective on medical practice." These programs largely look to the material examined by humanities disciplines—stories, poetry, painting, and history—to cultivate a productive empathy that can improve doctor-patient relations.

As such, the term "medical humanities" is largely a misnomer. The word "medical" in such programs refers not to the field of medicine broadly but almost exclusively to the clinical encounter. While it is crucial to improve medical communication and empathy, we should also be thinking capaciously about what the humanities can offer medical epistemology. Any given form of knowing, after all, imposes standards and rhetorical structures that necessarily constrain what can be known, and, given the myriad ethical concerns involved in the practice of medical experimentation and the limitations of current medical research to address widespread conditions, it is worth considering additional ways of investigating health. To undertake this work, we need to revisit not only what "medical" means for the medical humanities but also what the word "humanities" means in this context. On closer inspection, most programs that understand themselves as medical or health humanities do not make much use of the broad and powerful array of humanistic modes of inquiry; rather, they examine the same materials as humanities fields toward the ends of a well-meaning but vaguely conceived sense of empathy. The term "humanities" thus refers not to a set of rigorous intellectual and epistemological tools but to something more like an interest in humanity. In the conclusion, I argue that we must move past these articulations—often too loose and too limited—and insist on the intellectual potential of humanities tools, methods, and insights to shape and improve the health professions.

As the figures of this study demonstrate, this step is, in important ways, not a new one. As recently as a century ago—and long before that—doctors and writers used literature and the imagination to investigate, to know, and to practice medicine in the United States. Their disciplinary structures differed from ours, but we would do well to draw insights for our own times from their more precise and capacious understandings of the epistemological contributions of humanistic inquiry. There is not only a long prehistory to but a usable past for the medical and health humanities. The Medical Imagination thus concludes by calling for a sharper and more expansive articulation of what the humanities are and what they can do for the study of health and the practices of health care. Demanding such rigor will pave the way for more robust and useful iterations of the medical and health humanities in the future—moving the field more definitively from matters of feeling to methods of knowing.