Strange Cases

The Medical Case History and the British Novel

Jason Tougaw

• Publisher: Routledge
• Year: 2006
• eBook ISBN: 9781135510916
• Edition: 1
• Topic: Literature
• Subtopic: English Literary Criticism
• Index: Literature

Strange Cases is the story of the mutual influence of the case history

and the British novel during the eighteenth and nineteenth centuries.

Fictions from Defoe's Roxana to James's The Turn of the Screw and

case histories from George Cheyne's to Sigmund Freud's have found

narrative impetus in pathology. The writer of a case history faces a

rhetorical bind unique to the human sciences: the need to display the

acumen of a scientist and the sympathy warranted to the suffering

patient. Repeatedly, case historians justify their publicizing of

extreme, often morbid or perverse, states of mind and body by

appealing to readers to take pity on patients and to recognize the

narrative as a vital social document. Diagnosis and sympathy, explicit

rhetorical modes in case histories, operate implicitly in novels,

shaping reader-identification. While these two narrative forms set out

to fulfillan Enlightenment drive to classify and explain, they also

raise social and epistemological questions that challenge some of the

Enlightenment's most cherished ideals, including faith in reason, the

perfectibility of humankind, and the stability of truth.

Chapter One

Is Reading a Condition?

In Protocols of Reading (1989), Robert Scholes declares, “the condition of reading is the human condition.” It’s a grand rhetorical gesture, but Scholes is making a point that is by now relatively common: Life, like reading, consists of a series of interpretations, and since no perception is pure, we are left with “a reading of signs, rather than an apprehension of things” (69).¹ Scholes is a belletristic stylist but a post-structuralist thinker. His point about reading is a central tenet of the post-structuralist ethos that has dominated literary criticism since the 1980s, to the dismay of many of Scholes’s more purely belletristic colleagues. To read literature, they argue, is to engage in the ethical, moral, and intellectual life of the real world. It does not mean merely playing games with signs. A clear understanding of the historical and generic relationship between the novel and the case history, I will argue, can help reconcile these two positions. In a novel, the relationship between signs and things is ephemeral, too indirect ever to reconstruct. In a case history, signs are used to explain real-life suffering with the ultimate aim of alleviating it. Whether or not perception can ever be pure, the stakes of interpretation vary. However, even though novels have often been dismissed as silly or even dangerous, many novelists—Richardson, Burney, Eliot, Dickens, James—present their texts as vital social documents, as cures for social ills; and while case histories are vital social documents by nature, many of them contain the attributes of novels that tend to attract derision: sensationalism and melodrama, parochialism, didacticism, and undisguised authorial ambition. In fact, in many cases the disparity between signs and things is even more apparent, and often more disturbing, in case histories than it is in novels.

To begin his book on the British Enlightenment, The Creation of the Modern World, Roy Porter invokes Horace, whose dictum “Dare to Know” became a catch phrase of the intellectual revolution that fomented in eighteenth century Europe. Immanuel Kant cited it the impetus for his philosophical method, and the British magazine Free Thinker emblazoned it on its masthead. But dare to know what? Enlightenment thought, of course, made the entire cosmos its domain, its scope encompassing science, geography, politics, philosophy, economics, and the arts. Medicine’s role was peculiar because two prongs of Enlightenment thought converged in it, natural science and moral philosophy. The natural sciences—epitomized, in England, by the Royal Society—aimed to develop new methods of knowing the world, through direct observation. But medicine’s adoption of these methods was erratic, mainly because the objects to be observed were human beings, who were not as pliable under the scientist’s gaze as, say, rocks or butterflies.

In another of his massive surveys, The Greatest Benefit to Mankind: A Medical History of Humanity, Porter observes that divergent medical thinkers responded to the Enlightenment ethos with divergent theories and practical methods: iatromathematicians set out to quantify the body; mechanists compared anatomy to a hydraulic system, or as any number of other machines; animists denounced materialism and sought scientific evidence of a soul; anatomists, perhaps more practically, made encyclopedic illustrations of the body (245—49). Porter argues that “Historians have sometimes explained [the] apparent paradox of Enlightenment medical science—great expectations, disappointing results—as the consequence of over-ambitious theorizing” (248). For all the experimentation, in practice most patients found little alleviation from the bloodletting, leeches, crude surgeries, and noxious potions their doctors prescribed well into the nineteenth century. While the theorists lambasted tradition, the practitioners remained conservative, in my view, for two reasons: 1.) the “knowledge” produced through theory and experiment remained tentative at best and 2.) their patients were human beings whose lives, according to the same Enlightenment tenets that spurred both theory and experiment, were sacrosanct. This put the physician in a bind. He was required to live the era’s “dare to know” ethos and reassure his patients with his respect for the traditions that made them feel comfortable. To compound matters, more often than not, he was abundantly aware of what he did not and could not know, and he was entering his patients’ homes and witnessing private and often brutal bodily suffering. The observations of a working physician consistently betrayed another form of Enlightenment idealism, which held the sanctity of rational human beings above all else. Suffering patients were seldom rational, and the lives they led seldom ideal.

In literature, the corollary to the scientific method was realism, the close examination of characters in conditions that resemble the lives of ordinary people. In his book Before Novels: The Cultural Contexts of Eighteenth English Century Fiction, Paul John Hunter lists ten attributes of realist fiction that distinguish it from romance: contemporaneity, credibility and probability, familiarity, rejection of traditional plots, tradition-free language, individualism or subjectivity, empathy and vicariousness, coherence and unity of design, inclusivity, digressiveness, and fragmentation, and, finally, self-consciousness (23—24). All ten of these attributes are common to the medical case history, and most of them part of the general ethos of the new human sciences emerging in the period. All ten attributes, in literature as much as in medicine, direct attention toward pathology, rather than ideal portraits or systems, and ambiguity rather than certainty. Along similar lines, Geoffrey Sill argues, in The Cure of the Passions and the Origins of the English Novel, that the novel became a genre for exploring “the unsettled knowledge—or, as we might say, the crisis of thought and opinion—about the passions that waxed and waned through much of the eighteenth century” (3). As with so many subjects upon which the Enlightenment focused its gaze, the passions were the subject of scientists, philosophers, and novelists, and while large-scale debates about their origins, functions, and various pathologies waged, individuals, in life as much as in novels, wrestled with the day-to-day fluctuations and contradictions they induced. Whether the subject is the passions, or melancholy or gout or breast cancer, the irony inherent in a “dare to know” (or diagnostic) ethos is that its impulse derives from an idealistic view of humanity but directs its attention at the underbelly of people’s lives, whose realities tend to elicit confused and confusing portions of disgust and sympathy from onlookers.

Beginning in the eighteenth century and developing throughout the nineteenth, the novel and the case history were both very self-conscious about their ironic position in relation to Enlightenment thought, which had given birth to them but which their very existence called into question. Of course, as Porter acknowledges, there was never any single Enlightenment agenda, but a collection of enlightenment ideals, many of which were competing with each other for relevance or dominance. Every novel and every case history written during the eighteenth and nineteenth centuries contributed to these larger debates about self and knowledge, dramatizing states of mind and body that had previously been considered either too mundane or too private for narrative. The beginnings of these narratives rely on pathology as their enabling condition, eliciting a shock of recognition from readers; their middles take the strange and render it familiar by leading the reader through a series of events orchestrated into a plausible pattern of causes and effects; and their ends leave us with the ambivalence that comes from recognizing ourselves in a narrative of pathology. That recognition may be nineteenth-century narrative’s most enduring legacy.

Is reading, as Robert Scholes would have it, a condition? What does it mean to see life the way an Enlightenment diagnostician might, as a collection of signs to be interpreted? Applied to the many long, detailed novels of the period, Scholes’s assertion—that “the condition of reading is the human condition”—acquires a historically specific dimension. Read alongside their analogue, the case history, these novels all about the development of the self present us with a reading experience that exceeds Enlightenment ideals of independence and self-fulfillment. These narratives ask readers to concede the vulnerability they share with the suffering subjects that drive them, to examine the epistemological uncertainty and emotional flux that follows from our encounters with them. To read narrative is to exercise a skill for identification, and sympathy and diagnosis are the competing impulses that fuel identification. The hidden implication embedded in the act of reading is that only with a healthy skill for identification, in all its vicissitudes, can we forge a collective comfort zone for the fact that to be a self is to live with health and pathology, with free will and faltering agency. This, in the end, is what I think we learn from a Maggie Tulliver or a Dorian Gray.

Before I embark on the readings of specific novels and case histories in subsequent chapters, some background information is in order—in terms of the historical foundations of the novel and the case history and the theoretical and methodological underpinnings of this book. My project involves a dialogue between three basic genres: the novel, the case history, and literary and psychoanalytic theory on the question of reading. In the sections that follow, I will discuss first medical discourse in the novels of sensibility written during the latter part of the eighteenth century, forgoing a history of the novel per se, since there has already been a great deal of criticism on the topic, choosing instead to invoke and respond to that criticism throughout the book. By contrast, there has been little history or criticism on the medical case history, and so next I will outline the broad evolution of the genre as it developed over the course of the eighteenth and nineteenth centuries. Finally, I will survey narrative, psychoanalytic, and trauma theories, focusing on work that unites formal, psychological, and social questions, in order to develop my own theory of diagnostic and sympathetic reading.

MEDICAL DISCOURSE AND THE NOVEL OF SENSIBILITY

Because the novel of sensibility chronicled what G. J. Barker-Benfield has aptly named the “psycho-perceptual” experience of its protagonists, it is a good place to begin an analysis of the dynamics of reading and their relationship to the culture’s ongoing attempt to understand just what it is that makes a self. A descriptive survey of the roles of medicine in novels of sensibility demonstrates the extent to which fiction and medicine had become interwoven discourses by the end of the eighteenth century. The approach of these novels is analogous to the clinical approach of physicians: the narrator outlines a set of narrative and characterological problems and then uses the story to diagnose and “treat” the pathologies it represents. The novel of sensibility blended the clinical gaze of medicine with rhetorics of pathos, often invoking medical or empirical authority to justify explorations of difficult subject matter and then tempering such explorations with appeals to the sensibility of readers.

In his influential treatise A View of the Nervous Temperament (1807), Thomas Trotter took a cue from detractors who attacked the novel on moral grounds to launch a similar medical attack, suggesting that novels could actually cause disease and that they were dangerous for women in particular:

The passion of novel reading is intitled [sic] to a place here. In the present age it is one of the great causes of nervous disorders. The mind that can amuse itself with the love-sick trash of most modern compositions of this kind, seeks enjoyment beneath the level of a rational being. It creates for itself an ideal world, on the loose descriptions of romantic love, that leave passion without any moral guide in the real occurrences of life. To the female mind in particular, as being endued with finer feeling, this species of literary poison has been often fatal; and some of the most unfortunate of the sex have imputed their ruin chiefly to the reading of novels. How cautious then ought parents to be in guarding against the introduction of these romances, among their children; so calculated to induce that morbid sensibility which is so to be the bane of future happiness; which to prevent, is the task of a correct education; which first engender ardent passions, and then leave the mind without power to resist or subdue them. It is lamentable that three-fourths of these productions come from the pens of women; some of whom are known to have drank deep of the fountains of pleasure and adversity. (90–91)

Trotter holds novels at least partly responsible for what Cheyne called “the English malady” nearly a century before, an apparent epidemic of nervous disorders plaguing England. Because the “love sick trash” of novels stimulates regions “beneath the level of rational being,” even the practice of reading becomes the domain of medicine. Readers, Trotter suggests, over-identify with the plights of the pathological subjects of novels, putting themselves at risk for developing pathologies of their own. Rational minds, he implies, are fragile. Trotter sees women as particularly vulnerable because according to popular wisdom they are less familiar with the rational sciences and moral philosophy that might insulate them from the corrupting influence of fiction.

In 1778, more than thirty years before Trotter published A View of the Nervous Temperament, Fanny Burney had anticipated such attacks, invoking a medical metaphor in the preface to Evelina, a metaphor that forestalled perceptions of her and her female readers as sub-rational creatures. Burney does not de-gender the debate, but her defense does rescue women from the commonly held view that they are inherently uncritical readers:

Perhaps were it possible to effect the total extirpation of novels, our young ladies in general, and boarding-school damsels in particular, might profit from their annihilation: but since the distemper they have spread seems incurable, since their contagion bids defiance to the medicine of advice or reprehension, and since they are found to baffle all the mental art of physic, save what is prescribed by the slow regimen of Time, and bitter diet of Experience, surely all attempts to contribute to the number of those which may be read, if not with advantage, at least without injury, ought rather to be encouraged than contemned. (7)

Since novels, Burney implies, have already spread an incurable distemper, only life experience may relieve the symptoms caused by reading the fantastic, immoral, and unhealthy misinformation spread by fictions. A disease is rampant among young women readers, and Burney’s antidote is realism, because it offers vicarious life experience. In the next paragraph of her preface, Burney suggests a means of containing that spread—the realist novel:

Let me, therefore, prepare for disappointment those who, in the perusal of these sheets, entertain the gentle expectation of being transported to the fantastic regions of Romance, where Fiction is coloured by all the gay tints of luxurious Imagination, where Reason is an outcast, and where the sublimity of the Marvelous, rejects all aid from sober Probability. The heroine of these memoirs, young, artless, and inexperienced, is

No faultless Monster that the world ne’er saw,

But the offspring of Nature, and of Nature in her simplest attire. (7)

The implication is that readers have something to gain from realist fiction—a greater understanding of “Nature,” the world around them. In Burney’s preface, realist fiction is the only cure for the distemper spread by Romance. The novelist, then, becomes a kind of social physician, addressing readers and characters the way a physician addresses a patient, as “the offspring of Nature,” with a clinical eye for detail and, in the best circumstances, a host of prescriptions that will treat and sometimes even cure the maladies that afflict them. According to Burney, the representation of pathology has social value; it is preventive medicine for readers.

There was a general trend among both novelists and physicians of the period to disassociate from the “fantastic” narratives of their predecessors. In his 1793 “Letter to Erasmus Darwin,” Thomas Beddoes argued that the new medicine was explicitly a refutation of “The Old Medical Writers,” who made “distinctions based on the body merely imaginary” and whose observations were “not characterized by signs obvious to the senses” (6). It has been widely noted that, as a general trend, experience was displacing tradition as the authoritative means of acquiring knowledge in the modern, industrializing cultures of Europe in the eighteenth century.² Novelists and physicians were in a position to pursue the epistemological ramifications of experience, justifying narratives that chronicled the minutiae of experience on the grounds that they had tangible social value.

In Vital Signs: Medical Realism in Nineteenth-Century Fiction, Lawrence Rothfield argues that nineteenth-century British and French fiction—Flaubert’s Madame Bovary, Eliot’s Middlemarch, Zola’s Nana—is characterized by its clinical view of pathological characters, borrowing from scientific medicine a faith that details will yield truths. Rothfield suggests that the nineteenth-century tendency to medicalize all kinds of human behavior, as it is manifested in the period’s fiction, establishes the clinical authority of the physicians and narrators and objectifies patients and protagonists. Though they do not qualify as “medical realism,” novels of sensibility were already developing a clinical gaze that would be incorporated into these later texts:

Just as realism is more than the sum of its formal categories or techniques … so clinical medicine is more than a set of diagnostic assumptions or therapeutic methods. In both cases, the formal elements operate in history within an overall project to enforce a certain kind of authority. For the clinician, this authority is illustrated by his ability to convince others that a person is more truly defined as hysterical rather than, say, evil or possessed; as an alcoholic rather than a drunk; as obese rather than fat; as suffering from the pathology called homosexuality rather than committing the sin of sodomy. Insofar as novelists use clinical presuppositions, they also exploit this capacity to define the relation of self to body as a medical one. (xiii)

The predecessors to Rothfield’s “medical realism” were the novels of sensibility of the late eighteenth century. The clinical presuppositions of novelists depend on their invocations of medical authority, but many of these novelists also seem aware that the medicalization of drunks and sodomites has the immediate effect of redefining their social positions, making them objects of disgust and sympathy. The realist novel works on the assumption that the narrative representation of close observation will explain the complex and changing aspects of a life; it will sort them out, distill them into a core set of problems, many of them with solutions. Such an assumption has at least one major side effect: the detailed story of any pathology—how it started, how it feels, how it disrupts the trajectory of a life—is constructed to elicit a range of fear, aversion, disgust, sympathy, and understanding from readers. In novels of sensibility, perhaps more than in any other subgenre of realism, it is sympathy that is explicitly requested. And sympathy—an affinity between two subjects—tends to disrupt the sharply defined subject-object relations that allusions to medical authority might otherwise enforce in these novels.

In the eighteenth century novel, character is the primary marker of realism. As their titles suggest, the early English novels are lengthy, detailed studies of characters: Pamela, Clarissa, Roxana, Moll Flanders, Tom Jones, Joseph Andrews, Evelina, Cecilia, Caleb Williams, Belinda. Sill makes the point that the works of Defoe, in particular, “have since come to be read as novels, but … were originally to be read as natural histories of the passions—case studies of the perturbation of human nature” (10). In a less literal sense, all of these novels, insofar as they were influenced by Defoe and sprung from similar debates, fit Sill’s description. All of them, certainly, took as an influential precedent the natural histories and case histories that had become the representative genres of Enlightenment science. The influence of scie...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• Acknowledgments
• Introduction A Story of Two Genres
• Chapter One Is Reading a Condition?
• Chapter Two Science and Sensibility: Invasions of Privacy in Breast Cancer Narratives
• Chapter Three Narrating Hypochondriacs: Jane Austen’s Fiction and Three Case Histories
• Chapter Four Agents of Insensibility: Altered States in Victorian Medicine and Fiction
• Chapter Five “The Story Won’t Tell”: Ambiguity and Intersubjectivity in Henry James and Sigmund Freud
• Afterword Medical Agency and Human Remains
• Notes
• Works Cited
• Index