Book Abstract:
Revising the Clinic: Vision and Representation in Victorian Medicine and the Novel
Meegan Kennedy
Florida State University
Overview of the book
This book demonstrates the persistent linkage of literature and medicine by their reliance on similar methods of visual observation and written representation, even as they developed into discrete, often oppositional, practices; and it argues for the nineteenth-century novel's often contrarian uses of medical methodologies in producing a disciplinary knowledge. Revising the Clinic traces the paths of the nineteenth-century British novel and the medical case history as they approach or diverge, from sensibility to stream-of-consciousness. Both literature and medicine develop new standards governing observation and narration to underwrite their growing professionalism. Both literary and medical narratives strive to produce knowledge through a structure privileging a particular mode of vision and a verbal representation of that vision; and both figure realist and curious (exoticizing, sentimental, sensational, Gothic) discourses as necessarily conflicting alternatives within that structure.
Nineteenth-century novels and medical narratives share an interest in the strategic use of three different techniques of vision: curious "sight" or spectacle, realist observation, and human insight. These differing visual approaches crucially shape representation. In particular, Revising the Clinic maps the development of a clinical realist narrative of observation, as a mark of scientific progress in medicine and highbrow ambition in literature, in contention with alternate, "curious" narratives characterized by affective "sights"; and it examines the efforts of novelists to manage the use of both curious spectacle and realist observation in producing a humanist insight.
This book helps to open up a new aspect of novel studies by demonstrating that the archive of medical case histories offers a rich critical resource for illuminating the vexed history and context of the novel. The case history, although largely unacknowledged by criticism on the early novel, provides a compelling example of a developing narrative model for the novel, one that would not have been unfamiliar to many educated readers. The modern case history, which emerged with the rise of the novel, foregrounds its status as text. Like the novel, it is woven from diverse discourses; these become associated with distinct disciplinary identities and confer both professional benefits and disadvantages. The case history also shares a major concern of the novel: how to make a narrative of the self. By corralling the experience of the body within the frame of the text, the case history provides an alternative narrative structure, grounded in material events, that can model a coherent subjectivity accumulated through experience. The case history stands as a useful model for the novel, with its focus on reliably representing the narrative trajectory of a suffering subject. The novel likewise offers the ostensibly objective medical narrative a valuable resource of discursive strategies, but it also models a dangerously interested stance and a sometimes cavalier attitude toward factuality.
This book examines the tension within individual literary and medical narratives as they approach or resist a generic norm. This tension emerges from the historically-specific demand that the text establish professional identity and authority, an authority that could mean clinical reliability in medicine, or profound insight in the novel, but in both cases is grounded in an adequate and effective use of particular modes of observation and representation. Because I understand genre to be a historically-constructed, cultural form, the book combines a close formalist attention to texts and genres with a theoretically-informed analysis of historical practices. I examine a range of nineteenth-century novels, from the little-known to the canonical, and I draw upon years of research in eighteenth- and nineteenth-century primary medical texts, including casebooks, textbooks, manuals, and periodicals. The book pairs close readings of significant moments in these literary and medical texts with the study of publication history and a careful consideration of the relation between the text and its context. It reads shifts in form against changing professional pressures, class status, gender norms, national identity, and other discrete historical events and trends.
Introduction
The introduction to the book offers brief readings of Oliphant, Disraeli, Hardy, and the physician Bramwell in order to discuss the importance of theories of vision and representation to nineteenth-century authors and physicians as they develop generic norms for their narrative practice. It introduces the "case" as a category and reviews the development of its formal structure. It traces the interpellation of genre, discipline, and profession, and suggests what's at stake in reading novels alongside case histories, for critics of the novel and for Victorian studies.
Chapter One: Curious Observations, Curious Sights: The Eighteenth-Century Case History
Chapter One sets up the trajectory of my argument by establishing the narrative norms of eighteenth-century medicine. I show that medical and scientific prose during this century relied upon a model that transposes visual perception into knowledge through a narrative of structured vision. Experimental philosophers endorsed a narrative of curious but disinterested observation communicated by an early-realist "plain speech," but in practice they also used a spectacular narrative borne of an interested, "curious sight" and expressed in a curious (exoticizing, sentimental, sensational, Gothic) romantic discourse. I show that physicians often turned to the fanciful, ornamented, literary speech they disdained as "Rhetorick," in order to finesse the gaps in medical knowledge that were becoming more apparent in the context of new standards of truth and reliability. I examine George Cheyne and the papers of the Royal Society, including William Cheselden's case history of a cataract repair, to discuss how both experimentalist and spectacular narratives are channeled through and authenticated by visual exchange.
Chapter Two: Staging Clinical Realism: Performative Medicine in Victorian Periodicals
Chapter Two traces the emergence of the clinical (nineteenth-century) case history as a performative genre, one that uses narrative enactment to certify the author's identity, and argues for educated general readers' familiarity with the genre, despite growing distinctions between professional and popular medicine. I examine case histories from Giovanni Morgagni and The Lancet to show how the practice of dissection helped establish a new standard of clinical observation and scientific realist representation. This standard developed into a concept of mechanical observation, a skeptical ideal of "absent presence" in which the observer certifies his scientific virtue by removing himself as much as possible from the observation and the text. I examine treatises instructing physicians and patients on how to regularize and formalize the case history. Victorian novelists could become familiar with these ideals of medical observation and representation, since literary periodicals continued to model and discuss norms of medical practice through much of the nineteenth century. At mid-century, The Athenaeum , Cornhill Magazine , and Macmillan's Magazine published articles staging medical norms for a general audience. These combine accurate clinical observation and professional debate with a popularizing framework designed to dramatize scientific medicine as interesting and relevant to a lay reader.
Chapter Three: Sentimental Medicine and the Limits of Realism in Dickens and Gaskell
While clinical realism gains cultural recognition as the proper form for scientific medical narrative, sentimental medicine also persists in the clinical era. Charles Dickens and Elizabeth Gaskell redirect the visual techniques of realism strategically, to heighten ultimately sentimental insights. I read sentimental case histories, largely of failed medical interventions or "interesting" cases, against Dickens's deployment of a sentimental discourse in The Old Curiosity Shop and Dombey and Son in order to argue that Dickens references (and relishes) the curious sights of eighteenth-century medicine: individualized, saturated with sensibility, in which a patient's pathological body readily indexes his/her spiritual state of health or disease and invites an affective response. In such a context, the sentimental narrative usefully compensates for and supplements the inevitable failures of medical practice; these become ubiquitous, normative, and in a sense necessary. The eighteenth-century medical understanding of curious pathologies, with its insistence on the visual and affective participation of the reader, offers Dickens the opportunity to marry a sentimental aesthetic with the social reformist ideals often associated with his realism. Similarly, Gaskell's Ruth uses the very strength of her clinical depictions to drive home a moral aesthetic of sentiment and sympathy that threatens to transcend the very world it so painstakingly registers. The clinical narrative of Ruth's fever ironically becomes a means by which to transcend medical realities and affirm another narrative altogether, that of sympathy and moral virtue - in which the observation of disease acts as a mere window to make the spiritual world visible.
Chapter Four: George Eliot's Realist Vision, Mechanical Observation, and the Production of Sympathy
This chapter explores how novelists adapted and revised medical observation and narrative technique for their own purposes, often explicitly against the grain of clinical-realist ideology. By reading nineteenth-century clinical case histories against George Eliot's Adam Bede , I map the tension produced when both literature and medicine laid claim to a particular textual mechanism, a realism produced by mechanical observation, that novelists like Eliot employed to produce the insights of a "deep human sympathy" but that clinical physicians believed would protect against the intrusion of such subjectivity. That is, while the clinical case history shares with the nineteenth-century novel a realist narrative strategy for establishing verisimilitude, producing authenticity, and gaining narrative authority, novelists could borrow this strategy to produce a sympathetic insight that physicians criticized as dangerously interested.
Chapter Five: Speculation and Insight: Experimental Medicine and the Expansion of Realism
Middlemarch demonstrates a profound skepticism for mechanical observation alone, but the most enthusiastic faith in possibilities of clinical realism when combined with this intuitive, interpretive inner vision. A subjective involvement becomes necessary for the consummation of a realist vision. Remarkably, the novelist's insight here tracks a significant but little-recognized shift in scientific realism at mid-century: physicians' gradual acceptance of a judicious speculation, anchored (like George Eliot's) in clinical realism but casting out over a long depth of focus.
Conclusion: Freud and the Literary End of the Case History
In the conclusion, I use Freud as a telling vantage point on the discursive trajectory of the case history in its relation to the novel. I show that Freud's case history, despite his claim to inaugurate an entirely new science, in fact both invokes the objective, professional tradition of clinical medicine and resurrects the occulted, curious literature of eighteenth century medicine. "The curious" here re-emerges as a sexualized and sexualizing scrutiny, so that Freud must strenuously assert his prose to be scientific rather than literary, an experimental report rather than a roman à clef , in order to avoid attracting, or appearing himself to enjoy, a prurient interest in the case. I argue that Freud's complex imbrication of curious sight, clinical observation, and human insight both enabled his extraordinary case histories and forced him into the role of an embattled visionary, as he struggled to find a secure site of scientific narrative authority on which to found psychoanalysis. It was thus in part Freud's commitment to novelistic models that doomed psychoanalysis to its enduring success as a literary and cultural rather than a strictly scientific project. At the opening of the twentieth century, then, novelists could draw upon the clinical case history as an exemplary narrative of the real, and could turn to the Freudian case history as a provocative visualization of interiority. However, the novel itself had become altogether unavailable as a discursive model for medical prose, suspect in a clinical age for its very success in inhabiting, and eliciting, the subjectivity of another.