Jenny Davidson Talks to Sari Altschuler, author of The Medical Imagination

JMD: First of all, let me thank you for writing this amazing book! I’ve always been extremely interested in the history of medicine, and your book hits a sweet spot for me in terms of its combination of acute attention to primary sources with smart big-picture thinking about forms of knowledge. I especially appreciated your decision to focus the book around what you call a series of “epistemic crises,” in which “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,” bringing “problems of knowledge and epistemology . . . into relief” (13). It gives the book a clear through-line, and I found the chapters on cholera and anesthesia especially riveting and novel. Focusing on the cholera chapter as an example, would you be willing to tell the readers of The Rambling how you came to understand the primary sources in this way? Did you approach your primary sources with a hypothesis about a crisis of knowing, or did your sense of the power of the concept emerge more inductively from your work with your archive of materials?

SA: Thank you so much for this generous question! It took me a long time to feel my way toward a structure that fit the book. I basically wrote the project out three times: once chronologically with a narrower focus, once thematically, and finally with the focus on “epistemic crises.” At the end of the process, I, of course, wish it had been more straightforward, but I’m grateful for all I learned about the project along the way, and I’m glad I took the time to find a structure that fit it.

The first iteration of the cholera chapter, for example, wasn’t really about cholera at all. The first draft of the project focused instead on relationships between doctors and writers—on their intense friendships and their medical and literary exchanges. I was especially taken with Edgar Allan Poe’s relationships with a number of doctor-poets and became more interested specifically in his friendship with and influence on the physician-poet John Kearsley Mitchell (father of S. Weir Mitchell), although it took a while to narrow down the specific aspects of that relationship that were most compelling for the book. In the second draft, which I decided didn’t work either, I focused on keywords in medicine and culture (that material then moved into a chapter on “circulation”). It was only in trying to populate the chapter with other medical and literary figures that I came to see cholera as the hinge in that story. Once I identified cholera’s central role in changing medical paradigms, I realized moments like those shouldn’t just be the narrative climaxes of particular chapters, but they would be most compelling as the organizing principle of the chapters themselves.

All of this is to say that I actually came to the idea of “epistemic crises” very late in the process. The project really did emerge from years spent with the material rather than the other way around. Once I settled on the idea of organizing the chapters around crises of knowing, the rest came very quickly. It made intuitive sense to me that a book about ways of knowing should be organized around key moments that put pressure on strategies for knowing and revealed the insufficiency of available strategies. Those are the moments when creativity is clearest, most welcome, and most necessary.

JMD: The chapter on anesthesia is probably my single favorite. As a long-ago student of Elaine Scarry’s, I’ve always been interested in the relationship between pain and language, literary or otherwise, and I was absolutely captivated by your description of how the discovery of ether posed an upsetting set of questions for antebellum America: “What is pain? What is its role in life and health? And when is anesthesia (literally the state ‘without feeling’) useful—and when is it dangerous” (161)? You persuasively observe that these questions were unsettling “because they were not only epistemological but ontological,” and that writer-physicians found the novel at least as powerful a tool for exploring these topics as scientific research and publication. When did you realize that the development of anesthesia was an important episode in the story you tell that begins with arguments about republican medicine and the yellow fever epidemics of the 1790s?

SA: As is maybe the case for so many projects, all of the best parts of the book came late! I wrote the anesthesia chapter last because I needed the epistemic-crises structure to see how that material fit. It’s a different kind of chapter from the others, in part because it’s about a crisis of discovery rather than a crisis spurred by disease or politics and in part because I knew much better what I was arguing by the time I wrote it. Some parts, my own interest in pain, language, and knowledge, for instance, were there from the beginning, but they fit uneasily into the early chapters I drafted. I was also interested in S. Weir Mitchell from early on. He made a nice bookend—his father already played a prominent role in the story, and he and Oliver Wendell Holmes Sr. were prominent literary physicians during the rise of professional medicine in the US—but I didn’t want to spend much time on the already well-known story of Weir Mitchell’s relationship with Charlotte Perkins Gilman, which felt too late and already well-trod. (Readers will probably be glad I also resisted many Weir Mitchell wormholes connecting him back to the eighteenth-century chapters—his fascination with Benjamin Rush! his novel about yellow fever and George Washington’s second administration!) When I found Holmes’s letter to William T. G. Morton coining the term anesthesia, the rest fell into place.

JMD: You talk about the term communication and the many different senses it could convey: the transmission of disease, oral discussion, formal and informal correspondence, an item of news, the relationship between organs in the body or indeed between two geographical spaces (63). Has your current research brought any words of similar complexity to your attention, and if so, are you willing to share one with us?

SA: I have been working for a while now on a second book about disability in the early United States. I’m not sure the word disability is complex in the same ways, but I’ve been interested in the problems it poses for scholars in a period when modern understandings of disability were in the process of emerging. In the eighteenth century, for example, disability was not the central term by which people with particular impairments were understood, as Helen Deutsch has persuasively argued, but it was only one word of a number used to describe impairments, and its uses were different. It worked alongside words like defect, deformity, monstrosity, lamenessfeebleness, and idiocy. When disability was used, it often appeared in ways that probably strike contemporary readers as odd: you could certainly be disabled by sickness, of course, but you could be disabled by emotion, by ignorance, by lack of experience, and by distance. You could also be disabled from performing a certain task. In the late eighteenth-century US, disability names less an identity than a situational condition that might be removed. In the introduction to our special issue on “Early American Disability Studies,” Cristobal Silva and I take up some questions related to the inchoateness of the concept of disability in early America—questions that remain at the heart of my second book project—namely how ought we to work at the intersection of the idea of disability, the history of disability, and the word disability? What role does or should strategic anachronism—that is the use of the word disability informed by contemporary disability studies—play in this critical work?

On a different note, your question makes me think about something at the heart of both projects: an interest in how to think about words and concepts whose meanings are unstable, multiple, shifting, emergent (h/t Raymond Williams!). One of my favorite tasks in writing The Medical Imagination was researching the development of medical language. I became kind of obsessed with medical lexicons from the eighteenth and nineteenth centuries, and I spent way too much time reading them. Most of that work doesn’t appear directly in the book, but it’s probably clearest in the chapter epigraphs. The lexicons really show how philological medicine was in the eighteenth and nineteenth centuries. I think we have some sense of this when we think about all the classical knowledge in medical writing of the period, but these books are amazing tools for tracking the changes in medical thinking. I loved thinking about words like “Septon” (Samuel Latham Mitchell theorized it was oxygen’s antagonist and the cause of all organic decay) that bizarrely appear only briefly in the medical historical record—with much fanfare at the turn of the nineteenth century and gone just a decade later. That’s a very strange duration for the uptake of a medical concept in the period. Or, “cholera,” whose definition mushrooms (to use a metaphor of which cholera theorists were fond!) from just a few lines to many, many lines, as doctors try to capture in writing a very deadly and widespread disease they haven’t yet figured out. The changing shape of the definition over time remarkably resembles the movement and temporality of the disease itself.

JMD: You cast new light on a number of well-known works of literature, and I especially liked the way you are able to weave an argument out of many different kinds of sources. I was especially struck by your account of “The Fall of the House of Usher” as a story about fungal pathogens! I happen to have read a very appealing novel this past week, Chuck Wendig’s Wanderers, whose central topic is a fungal pandemic in a near-future America. It made me think about how speculative fiction, especially dystopian near-future fiction, has a good claim to be the genre where contemporary writers are most clearly performing the kind of imaginative and analytic work you admire in nineteenth-century America. Do you read in that genre, and do you have recommendations for the readers of The Rambling? Alternately, what contemporary American fiction do you see contributing in intelligent or important ways to conversations about medicine, health and ways of knowing?

SA: I completely agree about the place of speculative fiction as a genre where a lot of this work is happening today. I’ll have to check out Chuck Wendig’s Wanderers—what a serendipitous coincidence!

To take your question in a bit of a different direction, if I may, I’ve recently been really interested in the ways illness memoirs contribute to conversations about medicine, health, and ways of knowing. The illness memoir wasn’t a genre that existed as such in the eighteenth or nineteenth centuries, but these memoirs offer fascinating and really important spaces for working through bodily experiences that aren’t well-enough understood or treated by modern medicine. There are important creative and analytical elements of these books, too; it matters that these are well-written, thoughtful accounts of people who are trying to make sense of the various disjunctures between medical/cultural ideas about particular conditions and their own lived experiences.

Two recent books I would highly recommend along these lines are Porochista Khakpour’s Sick: A Memoir and Esmé Weijun Wang’s The Collected Schizophrenias. Khakpour’s book explores her struggle with late-stage Lyme disease—a diagnosis that has received derision and stigma from much of the medical establishment. There is too much to be said about the complexities around the experiences of people who identify as having late-stage or chronic Lyme and the medical literature on the subject, but, suffice to say, many people are very sick with conditions the medical establishment has a lot of trouble identifying or treating effectively. In an area where our diagnostic tools are not great, there is an unfortunately enormous difference between the way sick people who have a diagnosis get treated and the treatment those without a diagnosis receive. Wang’s book likewise unpacks the complexities not only of living with stigmatized illness but of diagnosis and the relationship between condition and care. And, like Khakpour’s memoir, a central part of Wang’s story is about what it’s like to live with a condition as both personal diagnoses and medical understandings of those diagnoses change. Health care professionals and researchers could learn a lot from these memoirs. They offer good examples, I think, of the need for “epistemological humility”—a concept I talk about in the book—that is, the need to be humble when thinking about what different ways of knowing offer and, additionally, accepting the necessary limitations of any one way of knowing.

It’s not an accident that these are both books by women of color. I find, even among my own students, women of color disproportionately drawn to and eloquent about the failures of health care in the United States. The reasons are too obvious: the structural racism and sexism in health care that impede certain kinds of discovery and diagnosis disproportionately affect their lives. The effects of racism and sexism in health care are not, of course, just about individual clinical encounters and personal bias, although that is one important set of problems this genre addresses. We should also look to these memoirs to identify the epistemological limitations of a health care system that remains in some ways fundamentally structured by racist, sexist, and ableist assumptions.

JMD: The Medical Imagination makes a powerful critique of the field of medical humanities as it is currently constituted. Your suggestion that “the medical humanities all too often emphasize the arts and humanities as ways of feeling rather than methods of knowing and conflate the humanities with a hazier notion of humanity” (198). I share your reservations about the field’s disproportionate emphasis on empathy, and I welcome your call for us to think more about what the humanities can offer medical epistemology. It’s intellectually reductive to think of medical humanities’ focus as being primarily an effort to use narrative and storytelling to help medical practitioners become more humane! I was curious to hear how established scholars in medical humanities, many of them institutionally as well as intellectually invested in the field, have responded to your work. More generally, what advice would you offer to young scholars looking to critique and transform the fields in which their own work centrally falls?

SA: This is a great question, and it’s something I worried about a lot early on. The pressure to argue that literature can make doctors more humane is strong in the medical humanities. You find it on most program websites, and many people in the field are very invested in proclaiming the power of literature and the arts to increase physician empathy.

I stopped worrying as much about how my critique would be received when I realized three things. First, there is a kind of cynical logic behind the call for empathy. I am not discounting the worthiness of projects aimed at increasing physician empathy, but the reason these programs get funded is because, in trying to make the humanities relevant for health professionals who are themselves looking for a way to ameliorate the dehumanizing effects of a bureaucratic and dollars-and-cents driven medicine, they ultimately aim to bring more dollars and cents to the humanities. It is no accident that empathy-promoting medical humanities programs have sprouted exponentially in the wake of the 2008 market crash and the national “crisis in the humanities” panic that followed. Cash for the humanities is a fine goal in and of itself (of course!), but it’s not, per se, the purely moral one that the empathy arguments often suggest. Second, there are, of course, people who genuinely believe in the humanizing power of art and literature, but, as you say, this is an intellectually reductive way of viewing what the humanities do. Reading literature to grow your own capacity for empathy isn’t so much a humanities approach to literature as an art appreciation approach; at the end of the day, it’s more the domain of book clubs than of literature classes, and it bothered me that the humanities were being promoted as largely about this kind of work. Third, I realized the humanities/humanism collapse at work in a lot of these arguments was coming principally from the health professions and humanists looking for a way to be relevant to those fields. It’s an easy one for health professionals to sign on to, unlike, say the kinds of intellectual and structural critiques of health that the humanities also levy. Like these medical humanists, I am also very interested in clarifying how our work is relevant to health, but not at the cost those “humanity”-promoting arguments bring. While well meaning, medical humanities arguments that make the humanities about feeling rather than knowing aren’t really offering a neutral position. After all, if the principal end to reading literature is just to make you a good person, wouldn’t it be best if you just had good people to read literature with you? And, if so, why do you need literature professors to do this? The answer is clearly that you don’t. In this way the empathy argument is a gamble with short-term appeal but potential long-term damage. Humanists have particular disciplinary expertise that should not be reduced to a naive appeal to feeling. Such appeals in the medical humanities borrow from the authority of the humanities while confusing people about what the humanities are and what they do. They ultimately evacuate the humanities of the need for humanists’ expertise. That’s a pretty dangerous thing.

All of this is to say, it hasn’t been as hard as I imagined to bring people on board. Medical humanists trained in the humanities have been especially receptive because I’m interested in emphasizing our training and skills rather than asking us to contort our work to the most palatable version for the health professions. There have been audiences of health professionals who were a bit more surprised and a few times defensive, but, in general, forward-thinking medical humanists in the health professions have also been really lovely, generous, and receptive. (As case in point: the section editor I worked with at the Lancet on a piece from the book was very supportive of my work, and the main editor of the journal has been publicly supportive of the humanities.) A big part of what I’ve tried to do with sympathetic medical humanists trained in the health professions is think about how to find common ground so that we can imagine new ways forward together. There, it hasn’t been so much disciplinary resistance to these ideas; the trick is in finding the right language through which we can communicate effectively with one another.

As far as advice to young scholars looking to critique and transform the fields in which they work, I’d say a couple of things:

First, if you sense there is a problem or a limitation to the field, hold on to that. It may take you a while (years!) to be able to articulate what that problem is effectively, but it’s worth holding on to. When you’re in grad school, you’re probably more up-to-date on scholarship than you ever will be afterward because that’s where and how you’re learning about the field. You’re also new to the ideas and can see them in fresh and exciting ways because they are still unfamiliar. For those reasons, it’s not surprising that you’ll see problems immediately that people who grew up with the field don’t—in part because they were part of getting the field to where it is.

Second, a caution about the first: be rigorous with yourself and skeptical of the problems you identify. The easiest move in grad school is to critique the work of others for what it doesn’t do. Try, first and foremost, to be generous, especially with the work of people who have paved the way for what you want to do, and think about whether your critique is a real problem with the work itself or simply an opportunity to work in an adjacent, compatible, or continuous direction.

Third, a related point: be strong but kind about your critique. It’s easy to think of people as strawmen/women. Especially if you’re just entering a field, it’s crucial to respect the hard work of the people who came before you and built your field. Think carefully about how to frame things, because, ultimately, the people you’re critiquing are likely also an important audience for your work, and you may even want them to be your collaborators down the line. Think about how to credit them with the work they’ve done and also how to bring them around to your perspective. For me, for example, some of the most energizing and difficult parts of the work have been trying to think about a language for the value of humanistic inquiry for people who aren’t humanists.

Fourth: you’re probably not alone. It turned out that other people were also dissatisfied with the haziness and imprecision of the medical humanities. So, while I was working on this, I found other scholars who were beginning to advocate for a turn toward the “critical medical humanities” or the “health humanities.” My own contribution to this conversation has been to think more precisely about what the intellectual contributions of the humanities are.

Fifth and finally: one exciting part of issuing this kind of critique is the possibility to build from it. It’s more compelling for other people and more intellectually generative—if harder—to think of things in that way. So, I’d counsel younger scholars to place the emphasis less on asking “what’s wrong with this field?” than on asking “what new things should this field be doing?” It may be necessary, as it was in my own case, to start by articulating the problem clearly, but I was most excited by the opportunity to envision my own answers through the idea of “humanistic competencies.” This work appears at the end of the book, and I’ve been lucky to try out at my home institution in collaboration with some of my colleagues. (See more here!)

Sari Altschuler is associate professor of English, associate director of the Humanities Center, and founding director of the Health, Humanities, and Society minor at Northeastern University. Her work has appeared in leading journals, including American Literature, American Literary History, PMLA, and the medical journal the Lancet and received long-term funding from the McNeil Center for Early American Studies, American Antiquarian Society, Andrew W. Mellon Foundation, and Wellesley College’s Newhouse Center. She is the author, most recently, of The Medical Imagination: Literature and Health in the Early United States (Philadelphia: University of Pennsylvania Press, 2018).

5 Questions With Jenny Davidson is a regular column of The Rambling Reads that features conversations with authors of recently published works. If you’ve recently published a book and would like to be interviewed, please get in touch with us.

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