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Listen: Sari Altschuler '01 on Literature and Health in the Early United States

Sari Altschuler '01 on "The Medical Imagination: Literature and Health in the Early United States"

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Sari Altschuler '01 returned to campus to discuss her soon-to-be released book titled "The Medical Imagination: Literature and Health in the Early United States".

An honors English literature and biology major at the College and recent addition to the English department at Northeastern, Altschuler is a leading voice in the study of early American medicine, the history of disability, and the medical humanities. Her scholarship has been published across a wide array of publications, including early American literature, American literature, American literary history, PMLA, and The Lancet. Awards and honors include the Society for the Historians of the Early American Republic Dissertation Prize and the Society of Early Americanists Essay Prize. Altschuler is also the recipient of prizes and fellowships, including long-term awards from the McNeil Center for Early American Studies, the Hench Postdoctoral Fellowship at the American Antiquarian Society, and the Andrew W. Mellon Foundation.

Audio Transcript

Don McLaughlin:                       Just introduce myself briefly. My name is Don James McLaughlin. I'm a visiting assistant professor in English at Swarthmore College this year, and it's my honor to be introducing Dr. Altschuler to all of you today. Before I get into the introduction, I just wanted to thank the English department without whom this event would not be possible. As soon as I proposed it to Peter this summer, he was eager to host it, and also I wanted to thank the health and society's group at the Lang Center for Civil and Social Responsibility, who has agreed to cosponsor the reception at the end of the event. I'd also like to give a brief shout out to my students in Medicine, Disability and Narrative, who have been thinking about a lot of the questions and conversations that are going to be coming up in today's talk and Q & A all semester and have been just engaging in really brilliant dialogue around questions around what Literature and Medicine have to say to one another.

                       And introducing Dr Altschuler to everyone today, I know many of you know her already. As a former alumna of Swarthmore College Dr. Altschuler is now an assistant professor of English at Northeastern University in a relatively short amount of time, Dr. Altschuler has become a leading voice in academia in the Study of Early American Literature and Medicine, but also in disability studies, disability history and the medical humanities broadly. She is the recipient of numerous awards and honors, including the Society for Historians of the Early American Republic Dissertation Prize and the Society of Early American Essay Prize. In addition, her research has been supported by an array of distinguished fellowships including the Hench Post-Dissertation Fellowship at the American Antiquarian Society as well as long-term awards from the McNiel Center for Early American Studies and the Andrew W. Mellon Foundation.

                       Her scholarship has been published across an array of venues as well including Early American Literature, American Literary History, and PMLA. Dr. Altschuler is incredibly intimidatingly prolific. It feels like every time I do another search on EBSCOhost, I'm finding another project she's been involved in, whether it's an essay of hers, or an array of essays that she's edited. I wanted to say briefly that one thing Dr. Altschuler is known for in the profession is her immense generosity of spirit. I actually met Sari for the first time at the American Antiquarian Society in Massachusetts when I was doing a month long fellowship, and I had read her work beforehand, and I looked across the reading room of the library, and I said, "No way, that's Siri Altschuler right over there. I have to find a way to introduce myself," and I finally got up the courage to do so, and Sari said, we should go get lunch and talk about your dissertation project. And we did that, and since then Sari has just been such an incredibly generous colleague and has given me so much good advice and feedback as I've gone through the transition from being in a Ph.D. to being on the other side, and I know that's true of a lot of other people as well. That being said, I think someone who is so generous is often announced in exactly that way.

                       So now, I just shift to talking a little bit more about the influence of her scholarship specifically. Dr. Altschuler reminds us, and this is what I think a lot of her work does, reminds us that the literary imagination, which is not just the stuff of good writing, but the imagination of poetry, fiction, and other creative modes is a key mode and unique form of intelligence that unlocks new ways of problem solving. And ways of thinking about the world. Her scholarship also shows us that moreover for early American physicians this relationship between medicine and this literary imagination was considered vital. In an essay she published in The Lancet last year she writes that according to early American physicians, such as Benjamin Rush, poets view phenomena with a microscopic eye and hence many things arrest their attention, which escape the notice of physicians. Doctors also wrote poetry themselves in earlier periods.

                       Physician poets had been a longstanding feature of the medical landscape, including people like Erasmus Darwin, Edward Jenner, and John Keats in the United Kingdom. In 1900, Canadian physician-poet, and I'm quoting, I should just reiterate, "William Osler observed it is remarkable how many physicians write poetry. I have been told of a period in the history of the Royal College of Physicians of London, when every elect (censor), as they were called had written verses." Altschuler reminds us that such poetry was exacting and precise. Rhyme, meter and literary devices helped to order the imagination and developed good thinking. So much of her work is about the way we can combine different modes of knowledge production and seeing the world to create new opportunities and thought and to reach new place of innovation that aren't possible if we just state in our individual fields and ways of thinking. So tonight we're going to hear more about these ideas as they unfold in Dr. Altschuler's forthcoming book, The Medical Imagination: Literature and Health in the Early United States. Please join me in welcoming Dr. Altschuler this evening.

Sari Altschuler:                       So I think that might be the most generous introduction that I've ever received, so I'm kind of speechless. But I just wanted to say, before I begin, to thank Don James McLaughlin, and the English department for inviting me to speak today. It is such a privilege and a pleasure to be back at Swarthmore. It really means a lot to me. I'd also like to just invite you to make the space the space accessible to you in whatever way it makes you most comfortable, so feel free to move around, to put your feet up, to [inaudible 00:06:36] to go out and come back in, to take notes and to do whatever else helps the space feel best for you. And finally and I'm just going to leave them here, but I have some large print access copies if that would be useful to you. In an 1872 essay on Goethe's scientific thought an aging Ralph Waldo Emerson observed, "Science does not know its debt to imagination."

                       In contrast, 100 years earlier, Goethe had "not believed that a great naturalist could exist without this faculty." He was himself conscious of its help, which made him a prophet among the doctors. Emerson's remarks encapsulate a shared feeling of regret echoed by a number of doctors and writers around the Atlantic in the late 19th and early 20th centuries. The physician-writer William Ostler, often called the father of modern medicine, urged his students both to pick up literature and philosophy and also to restore humanistic aspects of a medicine that was growing to scientific. Physician-poet Ronald Campbell McPhee likewise lamented medicine's unacknowledged debts in his book The Romance of Medicine, which he wrote to demonstrate, "The imaginative aspect and romantic character of medical discovery". And the avowed empiricist S. Weir Mitchell explained that "there are times when starting from facts, imagination is on the wing. It casts its treasure at the feet of reason."

                       A literary physician himself, Mitchell pictured this poetic imagination as a wild winged thing, that formed part of medical discovery. "The wild flight after the empirical proving may be hopeless", he wrote, "but seen with the idea of imagination, the page reads clear." Perhaps Emerson might have more accurately said that science no longer knew its debt to imagination, or at least that's what many feared. Like Emerson, Ostler and Mitchell, a number of turn-of-the-century doctors and writers struggled to be more explicit about the value of imagination and literary form for producing medical knowledge during a moment when professionalization was actively limiting medical ways of knowing. Whereas at the turn of the 19th century, professors wanted medical students to have a working knowledge of Classical Languages and Literatures. By the turn of the 20th century, medical education was being concentrated around more narrowly defined scientific topics. Emerson's words still ring true in the worlds of health and health care today.

                       The checklists and clinical algorithms of modern medicine leave little space for imagination and yet we depend on creativity and ingenuity for advancement in medicine to diagnose unusual conditions, to innovate treatment, and to make groundbreaking discoveries. We know a great deal about the empirical aspects of medicine, but we know far less about what the medical imagination is, what it does, how it works or how we might train it. This was not always so. In my forthcoming book, The Medical Imagination: Literature and Health in the Early United States, this is the new cover, I argue that the imagination and literary form were integral to the production of US medical knowledge between 1775 and 1866. During the 18th and 19th centuries, doctors understood the imagination to be directly connected to health, intimately involved in healing and central to medical discovery. The book traces a practice some I'm calling imaginative experimentation, a phrase that captures both the various ways in which doctors and writers used their imaginations to craft, test and implement theories of health and the role literary genres played in providing forums for their work.

                       Influenced by 18th century European and Caribbean doctor writers, U.S. physicians like Benjamin Rush used poetry to train judgment and imagination, to sharpen observation and to provide evidence for medical theory. Doctors and writers used novels, short stories and poetry to investigate questions that range from the origins of disease to the nature of human difference. And here, I actually just want to offer some visually suggestive examples of this work. So this is a poem from the very first issue of the very first US medical journal. It's called the Doctrine of Septon, and you can see that on the left side. Excuse me, that the medical theory is printed in verse on the left side, and then there's a medical gloss of terms on the right side in the margins.

                       And here are two other examples from the doctor-novelist Robert Montgomery Bird, in which he's working simultaneously on medicine and fiction, and in each the medical notes are on the left overlapping with the lines of fiction, which are on the right. Nowhere is the practice of imaginative experimentation more evident than in the moments of epistemic crisis that organized my book. From the American Revolution's radical refiguring of medical models to the remapping of medical geography in cholera's wake, to the fundamental reframing of pain and feeling brought about by the discovery of anesthesia, available ways of knowing failed spectacularly in the face of local, national and transnational developments. The practice of imaginative experimentation was especially visible in these moments of crisis, but it was by no means limited to them. The imagination was not a tool of last resort only to be used when other epistemological tools had failed. Rather, imaginative experimentation was a practice that formed part of a more flexible and dynamic complex of knowing. It worked with observation, physical experimentation, philosophy and history to produce medical knowledge in the period.

                       It flourished because it was grounded in the period's belief in the capacious powers of the imagination, in the robust practice of self experimentation, which was key to both 18th century medicine, and also to romanticism, and also in the crucial role the imagination played in understandings of health in the early United States. Imaginative experimentation thrived during a highly creative period in US history, when Americans were also busy imagining new social, religious and political forms. The book concludes, as this talk will, by arguing that this recovered history provides a usable past for contemporary conversations about the role of the imagination and the humanities in health research and practice today. So to give you more concrete sense of how this imaginative experimentation worked, I'm now going to turn back to antebellum America to show how doctors and writers turned the imagination into literary form when faced with the epistemic crisis caused by cholera's arrival in the United States. When cholera arrived in North America on June 6th, 1832, it was a wholly new disease.

                       It came from Ireland on a boat called the carrack and quickly moved down through Quebec and Montreal down the East Coast. Even though Americans had been steadily receiving reports of cholera's movements since 1830, its appearance surprised many who were convinced that cholera would never arrive, because they believed it was naturally endemic to India and could not cross the Atlantic. In this period before John Snow discovered cholera was waterborne and before germ theory, how cholera arrived, and how it claimed its victims was anyone's and everyone's guess. But when it did, the consequences were devastating. An otherwise healthy individual might have stomach pains in the morning, suffer vomit and diarrhea by noon, turn blue at 3:00 and be dead by nightfall. And this is just an illustration of cholera's quick work. This is a very common diptych of the common way of representing cholera.

                       This is from the Venetian iteration, a Venetian outbreak. And here are some images from the New York 1832 outbreak. This spectacular scourge kills half the people it infected, and doctors' almost complete inability to do anything about cholera dealt a profound blow to the rapid professionalization of American medicine in the 1830s. In the 12 years following the 1832 pandemic, 12 of 13 states repealed their medical licensing laws. With the limitations of a narrowly understood medicine made manifest, the variety of ways of medical knowing proliferated. Currently, we use medical cartography to try to respond to the kinds of pressing geographical questions cholera insisted upon, about the relationship between health and place, paths of transmission and the geographies traced by contagious disease. Cartography very familiar to us now from contemporary global health crises such as Zika and Ebola was surprisingly ineffective during the early cholera pandemics and I'll spend a few minutes first showing you why that is, and before I turned the ways in which imagination and literary form were used to produce medical knowledge about cholera.

                       A radical reframing of the landscape was a central effect of cholera. And mapping offered an early strategy for knowing this new medical geography. Newspapers for example reported people tracing cholera's path on maps at home. Thanks to the cutting-edge technology of lithography, maps could be produced suddenly much more cheaply and in far greater quantities, and so the practice of mapping proliferated in the 1930s. These maps responded aggressively to an issue at the heart of the epistemic crisis caused by cholera, which was namely how to understand the geography of health. The burgeoning practice of medical cartography promised new answers to pressing questions such as, "What made one place healthy and another diseased? Were some regions healthier than others? How did contagion travel? And were diseases contagious at all?" In the winter of 1831-32, Boston's A Sidney Duane published a volume on cholera to quell what he regarded as newspaper-spawned fears about cholera's imminent arrival. He himself was recently returned from Paris where the disease raged and Duane sought to offer what he called a consoling reflection that the facts constantly accumulating only confirm that the cholera morbus will not extend to us.

                       Advocating cholera's generally endemic nature to the Indian subcontinent and weakness outside of it, Duane emphasized that it could not reach the U.S. and he hoped that Americans would thus read his book, and this is awful, with pleasure. The central feature of the volume was a map of the chart of the progress of the cholera morbus in 1831. And what you can see here is that it's a pretty unorthodox perspective for a Boston made map. Its geographic imaginary is centered in India and Duane presses the continents up to both sides of the frames to offer a visual argument that cholera will not cross the Atlantic. However, when news about the carrack's sick passengers reached the United States a few months later, Americans needed new geographic imaginaries. So here's another Boston made map, this one by Ameriah Brigham in 1832. Whereas in Duane's map Europe and Asia were squeezed into a tight frame suggesting the containment of cholera, Brigham renders latitude and longitude effectively moot, eliminating the Atlantic, but to very different ends. Here Dublin is equal distance between Paris and Boston, and the tip of Florida aligns roughly with the Cape of Good Hope. There were also those who believed that cholera was not contagious. Proponents of local origin theories of cholera used maps to show that the disease was the result of locally dangerous conditions that produced what they called miasma or bad airs that came up from the land.

                       In 1833,  [inaudible 00:19:11] drew this very strange map of New York during the outbreak charting cholera's geography on a local scale and locating it in particular sites of cholera causing miasma in the city, while clearly delimiting its reach and what I love most is the attempt here to visualize the bad airs moving across Manhattan. Henry Schenck Tanner took a different approach to mapping miasma. He used a highly conventional Mercator projection, this was the most conventional of the maps, to argue that color was anything but novel. The scale of Tanner's map visually diminishes the effect of cholera and his distinct zones argue that cholera was neither new nor contagious. This is actually meant to represent years not movement. By "not new", the local origins advocates meant that cholera was a variant of known diseases, just worse because of local environmental changes like those that had resulted from the period's rapid urbanization.

                       Nevertheless, the knowledge that both types of maps produced was necessarily limited by the movement of the disease itself in real time, namely the movement of cholera persistently undermined the kind of comprehensive knowledge men like Tanner and Wayne sought to produce. If we return to this, which is an insight from the British Isles from Twain's 1831 map, we can see that he then had to update it after it was printed to include three 1832 outbreaks that occurred after the map was conceived in Edinburgh in January, in London in February, and Dublin in March. Yet more information became available between the time that the map was printed and the time it was circulated and so hand-drawn lines converge on an undated Glasgow outbreak. In other words, the compelling medical knowledge produced by this cartographic imaginary was nonetheless necessarily belied by its own pretense to comprehensiveness.

                       The tension turned cruel irony when the Massachusetts Medical Society attached a note dated June 7th to a volume that included Dwayne's map declaring that they hoped to hear more from Europe "when the epidemic has subsided". The carrack had docked in Quebec just one day earlier. Likewise, while local origins proponents like in this map made by Tanner ... When Tanner drew his map to counter "the common and absurd motive delineating by very definite lines the exact root of the pestilence from place to place", and that's in italics with many exclamation points. He nonetheless still traces cholera's route from Montreal down through Virginia and I liked that the red kind of occludes it, but also feels the need to have it anyway. Thus while medical maps offered an appealing way of knowing the geographical problems that cholera raised cartography's epistemological limits were also clear. For the rest of the talk, I'm going to talk about another form for investigating cholera's as radical geographies: the Gothic.

                       In particular, I'm going to focus on the collaborative theorizing of Gothic medical writers Edgar Allan Poe and his friend, the physician poet John Kearsley Mitchell, and I just want to say they were friends in Philadelphia, and the things that they produced were produced just a few miles from here. And the chapter also includes pieces on Harriet Beecher Stowe and Martin Delaney and I'd be happy to talk about that afterwards if it's helpful. Poe avidly followed and participated in antebellum scientific and medical developments. The inspiration for at least one of his stories has been credited to his familiarity with the medical work of A. Sydney Dwaine. And stories like The Sphinx, King Pest, and Masque of the Red Death reveal his sustained interest in medical geography and in the ability of disease to radically reframe familiar spaces. His scientific interests have been repeatedly celebrated as we can see in this 1895 declaration from The Lancet proclaiming Poe's fiction anticipates science.

                       Or in these later articles from JAMA and The Lancet celebrating Poe's [inaudible 00:23:37] descriptions of conditions decades before their discovery in the medical literature. But fiction like Poe's did not merely anticipate science. Fiction also wrote it. In what follows, I read Poe's 1839 Fall of the House of Usher as an imaginative experiment with medical geography in the wake of cholera and I demonstrate how Poe's theorizing in the story made its way into medical literature by the 1940s. Poe did not turn to cartography to do so, however. Rather, he like many doctors and writers at the time, turned to the Gothic with its terrifying suspense, hidden passages, decaying walls and unstable geography to represent the effective experience of cholera and its narratives, to remap medical geography, and to reconcile the two camps of medical thinking about disease.

                       The form of the Gothic better fit Poe's understanding of the world in cholera's wake and his imaginative experiment provided a venue in which he could propose fungus as a solution to the pressing questions about the geography of health. So just a quick plot refresher, although I'm sure many of you are familiar with the story. The Fall of the House of Usher is the story of a man who answers the request of an old dying friend at his ancestral mansion. The unnamed narrator arrives in time for the death of Usher's sister Madeleine, whom they bury in the walls. The narrator tries to use reason to resist what he perceives to be Usher's increasingly frantic illness [inaudible 00:25:15] delusions only to be proven wrong and drawn into Usher's world, when the bloody Madeleine reemerges from the grave to collapse on the body of her brother. The narrator flees the scene, the house collapses into the pond below.

                       The story opens with a lone rider passing into a decaying landscape. The trip should have been a kind of homecoming for Poe's protagonist, who travels a familiar route to his childhood friend's ancestral home. But the atmosphere is moist with clouds that hang oppressively low, rank sedges and decayed trees. De-familiarized, the space produces an iciness, a sinking, a sickening of the heart, which the narrator connects with the symptoms of an approaching illness. The narrator insists that he cannot understand the mystery that produces these feelings but they begin with the moisture of the decomposing plant matter, and the still water that hideously mirrors decaying foliage. Gray sedge and ghastly tree stems surround the house of Usher. More than a simplistic use of pathetic fallacy, Poe writes a landscape made strange that recalls both miasma and the geographic disorientation caused by cholera.

                       But Poe's story is embedded in an environment not merely brimming with miasmas, bad airs, but fully overrun by fungus. Though the story "seems a thesaurus of Gothic cliches", the critic J. O. Bailey noted more than 50 years ago, he writes, "The typical gothic castle is hung with moss or Ivy. Poe's fungus seems a unique and more deadly parasite invented for a purpose to be examined." That's all he says. The story is set in the fall, peak season for fungal growth. The narrator approaches a decaying house and peers into the tarn, envisioning about the whole mansion and domain an atmosphere peculiar to themselves and their immediate vicinity, an atmosphere, which had no affinity with the era of heaven, but which reeked up from the decayed trees and the gray wall, and the silent tarn a pestilential and mystic vapor, dull, sluggish, faintly discernible, and leaden hued. But the narrator convinces himself that this diseased atmosphere must have been a dream. Shaking off these perceptions, the narrator turns to objective scrutiny. "I scanned more narrowly the real aspect of the building."

                       He discovers an old discolored edifice with minute fungi, which overspread the whole exterior hanging in a fine tangled web-work from the eaves. Although he sees no other signs of excessive decay except a faint crack in the building's façade, he observes that in this there was much to remind me of the specious totality of old woodwork, which has rotted for long years in some neglected vault with no disturbance from the breath of the external air. Once the narrator enters the house, Poe strengthens his sense that the space and the story are permeated by fungus. The shaken Usher attempts to retreat from his own illness into a ballad called The Haunted Palace, but he picks a story that offers no relief from the surrounding conditions. Rather, the ballad leads Usher to contemplate the perverse sentience of all vegetable things. I love that line. More particularly, the ballad leads Usher to dwell on this sentience as it is fulfilled in the method of collocation of the house's stones in the order of their arrangement as well as in that of the many fungi, which overspread them and of the decayed trees, which stood around above all in the long, undisturbed endurance of this arrangement, and in its reduplication in the still waters of the tarn. Here, the narrative suggests a medical geography to Usher that terrifies him.

                       He's haunted by the so particularly ordered stones of his own house, which like the trees without, decay from the inside by the fungus that surrounds them. Only the word fungi is italicized. The Gothic wasn't especially appropriate genre for theorizing fungus. Fungus grew at night in untended spaces and multiplied at a seemingly unnatural rate. It worked stealthily. The spread of fungus and its rotting of plant and animal matter occurred almost imperceptibly and scientists described the fungal cells as invisible. Furthermore, in the 1830s, scientists could not decide if fungus was plant or animal. It appeared rather to be an unnatural plant that needed no sun and flourished in the darkness. And new developments in microscopy revealed that these unnatural fungal cells were dangerously indistinguishable from animal cells. Fungus surreptitiously spawned as scientists explained from an almost invisible single cell to a cloud with 10 million sporules so minute as to look like smoke. Refusing to sit lightly on the facade of the House of Usher, fungus infiltrates its core and becomes an explanatory paradigm for the story. Usher's decaying body metonymically corresponds to the fungus-eroded house and ancestral line.

                       His hair with its more than web-like softness and tenuity stands in for the minute fungi that overspread the whole exterior hanging in a fine tangled web-work from the eaves. Furthermore, the collapse of otherwise disparate identities, Usher Madeleine the narrator reproduce the fungal cell's ability to mimic and invade plant and animal cells. The effect of the corrupted stones, the narrator explains, was discoverable in the silent yet importunate and terrible influence, which for centuries had molded the destinies of his family, and which made him what I now saw. Poe's dark pun on the families' molded destinies reveals the fungus's dangerous permeability. The story's textual history also emphasizes the centrality of fungus. Some subtle but significant changes were made to The Fall of the House of Usher between the 1839 magazine edition and the commonly reproduced 1845 edition from Poe's Tales that highlight Poe's increasingly scientific interest in fungus. In the latter edition, Poe added a footnote citing four scientists to support Usher's belief in the sentience of all vegetable things.

                       The footnote here reads "Watson, Dr. Percival, Spallanzani, and especially the Bishop of Landaff.See Chemical Essays, volume 5." And in 1845 Poe also breaks the long paragraph introducing the fungi into the story for emphasis. In earlier editions Poe buries the minute fungi that overspread the whole exterior nine sentences into this paragraph, whereas in the 1845 edition "The real aspect of the building becomes its own paragraph. More clearly foregrounding the responsibility of the minute fungi for the perfectly preserved but fully rotten condition of the House of Usher." Finally, the 1845 edition shifts the italics from "The gradual yet certain condensation of an atmosphere of their own about the waters and the walls", which reads very much like a contemporary description of miasma to a single italicized word in 1845: fungi. The timing of Poe's revisions coincides with his friendship with the Philadelphia physician poet John Kearsley Mitchell, who I should mention as Weir Mitchell's father. Both were physicians.

                       Both were Virginians living in Philadelphia and Poe greatly admired Mitchell's writing, more than once coming to his literary defense. Mitchell was both friend and physician to Poe even lending him money on occasion. Actually lots of people did. This slide is actually an early daguerreotype, which captures the scientific nature of their friendship and that's likely Mitchell on the left and Poe on the right. The developments of Mitchell's medical and scientific work is deeply indebted to both his experience with cholera and also his friendship with Poe. Although Mitchell penned both medicine and literature in the 1830s, his early poetry was sentimental and adventurous, while his medical writing was stoic and technical. In the 1830s, Mitchell was a chemist whose essays on the permeability of natural boundaries prepared him for his cholera work. So these are examples of the kinds of essays that he wrote.

                       In these essays, Mitchell explored his hypothesis that permeability was the key to the health of American bodies and environments. Nevertheless, after Mitchell almost died of cholera his understanding of the geographic and corporeal permeability took a darker turn. The early 1840s afforded Mitchell the opportunity to develop his work on cholera in concert with his friend Poe. In the mid 40s as a newly appointed Professor of Medicine, Mitchell began delivering a lecture that he called On the Cryptogamous Origin of Malarious and Epidemic Fevers, and malarious he refers to any fever called caused by mal aria or bad airs. The essay offers a Gothically inflected argument that fevers particularly yellow fever and cholera arise from minute fungi that proliferate unseen in the environment. The reader is prepared for Mitchell's Gothic medicine by this evocative title. He might have chosen a neutral term "fungal", but instead, he chose its synonym, "cryptogamous" to indicate the fever's origins in spaces wedded "gamous" to the hidden, concealed, secret "crypto".

                       Fungal theory creatively reconciled local origins and importation theories of cholera. Unlike miasma, which insisted that the disease arose from mysterious vapors that emerged from the local landscape, fungus grew locally but it could also move. Weighing the apparently contradictory evidence that cholera was portable yet not contagious, Mitchell remarks, "No wonder that men were puzzled and perplexed being contagionists in one time and place an anti-contagionists in another. If we assume for cholera a fungous origin," however, Mitchell proclaims, "all difficulties vanish." Fungus explained cholera's noncontagious circulation, because of its unusually fast expansion, replication and dissemination, as well as its easy transport via goods, ships, people and the wind. For Mitchell, fungi, which he called the "Goths of phytology" bear the spirit of Poe's dark tales. Fungi, and this is not emphasis at it, fungi are distinguished for their diffusion and their number, Mitchell writes, for their poisonous properties and their peculiar seasons of growth for the minuteness of their spores and for their love of darkness and tainted soils and heavy atmospheres.

                       Fungi terrifyingly refigure familiar geography through movement too small to see. Furthermore, they work at night, a time that Mitchell believes all infection took place. "Darkness appears to be essential either to fungal existence or to its power. The dangers of these "dubious beings" arise from their invisibility, enchantment, unnatural inversion of the vegetable order, love of darkness, and the fact that they could scarcely be microscopically distinguished from the primordial formation of our own selves. Fungi produced additional fright because of their blood like appearance and filled observers with disgust and horror. They bear names like Merulius [inaudible 00:37:37] and Polyporus destructor. Mitchell worried that his readers might doubt the terrifying power that he attributed to the fungi, and thus he reminds us what little quantity of material is needed to infect a person. "A mushroom growth is proverbial in every language. In a single night under favorable circumstances, leather or moist vegetable matter may be completely covered with mold. Of the more minute fungi some species pass through their whole existence in a few minutes from the invisible spore to the perfect plant. Fungi could indeed reproduce and move quickly and expansively mimicking patterns of rapid contagion."

                       Certainly, these descriptions of uncanny doubling, the lack of ability to distinguish between [inaudible 00:38:25] cells and other cells, rapid reproduction, invisible forces, soundless destruction, semblance to blood, enchantment and horror bear a striking resemblance to post-Gothic. Likewise, Mitchell's emphasis, particularly his use of haunting description, strategic repetition and italics are reminiscent of Poe's narrative form. Mitchell's work literary or medical bore no traces of these gothic strategies before he met Poe. What makes the geography of diseases like cholera so terrifying, Mitchell explains is the near impossibility of discerning empirically what makes one place healthy and another disease-ridden. Two places with similar elevation, local relations, atmospheric phenomena, and geological structure may differ totally in their degree of helpfulness. The line of limitation of disease-producing power may be a common road, a narrow street, a stone wall or a belt of woods. Mitchell's reflections recall post narrator, who cannot understand what it was that so unnerved him about the House of Usher. He reflects that possibly a mere different arrangement of the particulars of the scene, of the details of the picture would be sufficient to modify or perhaps to annihilate their effect.

                       For poet Mitchell, it was here that the imagination and literary form could help. While the questions cholera raised about medical geography seemed to resist ordinary practices of empirical study like observation and mapping, the Gothic allowed Mitchell to theorize cholera in terms of barely visible fungal growths that traveled through networks of transnational trade from St. Petersburg and London to Canton and down the St. Lawrence. To be completely clear, I'm saying that the Gothic was an incredibly powerful forum for understanding the global cholera pandemics, more powerful in a number of ways than the empirical methods available at the time. Observation and experimentation contributed to developing knowledge about the disease, but empiricism had its limits and the imagination allowed doctors and writers to move beyond what could be experienced and tested directly. The Gothic was a form that already concerned itself with difficult to understand shifts that de-familiarized spaces and that already traced the uncanny infiltration of Western spaces by the East, and I would be happy to talk about the ways in which this stuff is racist and xenophobic, but also the legacies of that today.

                       That's sort of a side note. The idea of the fungal origins of fevers was pervasive enough to prompt a transatlantic debate about its discovery. But contagion and medical mapping would of course win the day. In the very year that Mitchell finally published Cryptogamous Origins, 1849, the British physician John Snow hypothesized correctly that cholera was waterborne and this is perhaps a very familiar map from 1845 that Snow used to trace the instances of cholera in London and since the early 20th century, epidemiology and public health have heralded its creation as their origin story for their births as fields. And as a side note, this is also much more complicated. Nevertheless, we do an injustice to medical history if we read only with this endpoint in mind. Tonight, I have argued for the history of humanistic inquiry in medicine. Maps won out but it was by no means clear in the 1930s and 40s that they would.

                       In fact, in arguing for the causes of cholera in almost imperceptible not animal or plant particles that were quite portable and easily permeated the boundaries of the environment and the human body, Poe and Mitchell identified something fundamental about the disease that wouldn't be empirically corroborated until 1884. For this talk however, I've asked us to pause in the antebellum moment when cholera posed a serious epistemological and ontological challenges to global health and Americans turn to a variety of practices, including imaginative experimentation to know the disease. As the 19th century wore on, it became more difficult for physicians to turn explicitly to their imaginations in medicine. Two events formalized the shift, revamping medical education and those were the founding of the AMA's Council on Medical Education in 1904 and the publication of the Carnegie Foundation's Flexner Report on medical education in the United States and Canada in 1910. In the first few years of its existence, the council set out new rules for medical education.

                       Doctors now needed four years of secondary education, four years of medical school and a passing grade on a licensing exam in order to be certified. The Flexner Report made these new requirements yet more specific, placing an emphasis for a new medical training system on particular kinds of scientific knowledge. In proposing these changes, the Flexner Report offered a medical history as a declension narrative. "American medicine had once been great but had fallen into terrible disrepair, Abraham Flexner warned, and a vast army of men is admitted to the practice of medicine who are untrained in the sciences fundamental to the profession." The report did not imagine these sciences rapaciously but understood them through rigid disciplinarity. Whereas in the 19th century entering medical students were expected to arrive with a knowledge of the classics, in the 20th century, Flexner hoped that they would bring a competent knowledge of chemistry, biology, and physics. Flexer was immensely effective in realizing this shift, and his report was used to craft our current, well also changing as we speak, but for a hundred years, our system of medical education.

                       Nevertheless, there was some irony in this given that the report's author Abraham Flexner was not a physician, but rather an educator trained in the old tools of the trade: Latin, Greek, and philosophy, who had never stepped into a medical school before he was tasked with preparing the report. In fact, Flexner quickly regretted his recommendations. In 1925, he wrote, "Scientific medicine in America, young and vigorous and positivistic is today sadly deficient in cultural and philosophical backgrounds. Something more intellectual is also needed." But the ship had already sails, and it is to the system he helped to implement that we owe our contemporary medicine, which has vastly improved the science but much less the art of medicine. I'd like to and then with a few provocations about how we might use this history that I've traced to imagine a future for the medical and health humanities. Certainly, doctors and writers in the early republic had distinct disciplinary structures that do not map easily onto our own.

                       But I'd love to advocate recovering the spirit of their inquiries for ourselves. If what the 19th century returns to us is a version of medicine that used a complex of knowing in which imagination and literary form were compatible with philosophical and impure approaches to medicine, how then can we recapture the sense of the specific value of humanistic inquiry in health? The medical and health humanities, while incredibly popular, and here's my more contentious claims. So I'm flagging them, while incredibly popular tend to remain frustratingly vague about the contributions that the humanities can make to health. Leaning on qualities like empathy, which while very noble in its own right of course, is at best and if we're honest not actually what humanities scholars are trained to cultivate. At worst, this emphasis on empathy can evacuate the humanities of their capacity for analysis, training and critique, and risk making the humanities not the domain of experts, but rather the expertise of every right feeling person. Instead, I'd like to propose a health humanities approach based on the contributions that humanists are trained to make.

                       The concept that I've been developing to describe this approach is one of humanistic competencies, which names a set of terms that I've been developing including, observation, attention, judgment, narrative, historical perspective, ethics and creativity that draw attention to the specific competencies the humanities train. Here, I'm of course building on the work of leading scholars in the field, like Rita Sharon who has argued for narrative competency, and a group of art historians who have demonstrated that art history can help train physicians in observation. But I'd like to extend these competencies farther, recognizing that competencies like narrative, observation and creativity are not the domains of particular disciplines, but rather competencies that might benefit from the perspectives of a collection of humanities disciplines. Think for example how the close reading of literary scholars and the histories of observation familiar to historians and the novel ways of understanding looking promoted by disability studies scholars might augment a competency and observation as art historians imagine it.

                       Creativity is another humanistic competency that can help health professionals improve their work. In this talk, I've been suggesting the long history of the medical imagination and the varied ways in which doctors and writers employ their imaginations and literary form in the service of human health. While many medical humanities programs use paintings, literary texts, historical documents and philosophy to cultivate a vaguely conceived sense of human interest or empathy, the humanities use those same objects to train creative analytical thinking. Reassembling knowledge, experience and observation creatively toward new discovery, the humanities privilege the unexpected, the unanticipated, and the precise, rather than the routine and the strictly procedural. Informed by historical precedent, structural understanding and an ability to dwell in ambiguity, the humanities can also help students develop an ethical dimension to that analytical creativity, educating future health workers toward new insights while also bearing in mind the potential stakes and consequences of such work. Here again, the more rigorous and specific we can be about what the humanities do, the better medical and health humanities can be. Given time limitations, I can only be brief about those possibilities of making medical and health humanities more rigorous, but I hope I've suggested how the dynamic complexes of knowing from the past can help. And I'm looking forward to the conversation.

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