Learning from Crisis: Narrative and the History of Medicine

Sari Altschuler

“Attack on the Quarantine establishment on September 1, 1858,” from Harper’s Weekly, Sept. 11, 1858. Courtesy of the Library of Congress.

COVID-19 has brought about an epistemic crisis in medicine: a moment when available ways of knowing fail to account for or provide adequate response to an event, and new ways of knowing are needed.[1] When news first emerged out of Wuhan, many talked about a “novel coronavirus,” a phrase that suggested COVID-19 was both new, but also reassuringly known. It seemed to be an upper respiratory disease caused by a virus—something between a cold and SARS. Nevertheless, certitude quickly fell away as doctors and researchers discovered their lack of information about how the virus worked, how to prevent infection, or how to treat the sick. Caught on their heels, doctors in hospitals and medical researchers have been considering strategies otherwise anathema to twenty-first-century medicine: organizing knowledge around studies before peer review, rushing human vaccine testing, and experimenting with medications and therapies not approved for the disease. Additionally, there has been more authority given to patient self-knowledge, alternative practices, and imaginative solutions, as well as, of course, fake science and quack medicine.[2] We have yet to know what outcomes will look like, but some foundational elements of medicine will undoubtedly change. We would like to think this will be for the better, but, frankly, we cannot know. Triumphal narratives about medicine are failing us.

Despite the excellent work of some historians, sociologists, and cultural theorists of medicine, Whiggish histories of medicine remain stubbornly entrenched. It’s true: the history of medicine boasts a long line of important discoveries and advances, as well as increasing the health and lifespans of individuals globally. At the same time, to think of medicine as progressive and teleological in this way belies the more contested and messy process of knowledge production especially on display in times of crisis. Too often, as medical sociologist Owen Whooley writes, histories of medicine unwittingly uphold “truth-wins-out narratives”—or what Bruno Latour critiques as the “diffusion model” of knowledge production—where even histories that dispense with teleology nevertheless adhere too strongly to a belief that when certain discoveries are made they display self-evident truths that move medicine forward.[3] Arguably, this may be the result of historical confluence: Not only have doctors long had their thumb on the scales of medical history—“until recently . . . a history written by and for practitioners”—but medicine and history both rose as professional disciplines in the same progressive-era sweep.[4] Furthermore, such historical plots may have been easier to believe for much of the twentieth century when empirical medicine had more power, authority, and hegemonic intellectual control in the United States than today or during the early republic.

In recent years we have seen a plurality of medical knowledge that, perhaps surprisingly, better resembles the early republic than it does, say 1918. During the early republic, medicine underwent an epistemological sea change. Charles Rosenberg describes this shift in The Cholera Years: between 1832 and 1866 “a more critical and empirical temper had begun to replace the abstract rationalism of an earlier day. In medicine . . . thoughtful physicians scorned those concepts which could not be expressed in tables and percentages.”[5] And, as John Harley Warner explains, this shift was messy: Rationalism and empiricism were both hotly contested and also so unmoored in antebellum America so as to be sometimes exchangeable for one another. Far from presenting a clear before and after, the “integrity of [medicine’s] vocabulary” had, in Warner’s estimation, been so “destroyed” such that “the terms rational and empirical taken by themselves were all but meaningless in medical discourse.”[6]Medical epistemology was structured by the epistemic crises that took place during this period—particularly cholera. Whereas by 1832 thirteen states had passed licensing laws to professionalize U.S. medicine, by 1844 twelve were repealed and by 1851 regulatory laws had been rescinded in fifteen states.[7] Furthermore, of course, knowledge-making did not change all at once; it progressed unevenly across time, space, and professional position.[8]

Reverence for empirical medicine has fallen away in recent decades, especially with the Internet’s democratization of information but also because of vital critiques exposing the racist, sexist, homophobic, and ableist logics that shaped medical knowledge during the twentieth century. This situation is only exacerbated by the COVID-19 pandemic. As David Jones recently explained of our collective hubris: “Writing in the heady days of new antibiotics and immunizations, esteemed microbiologists Macfarlane Burnet and David White predicted in 1972 that ‘the most likely forecast about the future of infectious diseases is that it will be very dull’. . . . Times have changed.”[9] We stand to learn more about the present and the past by thinking differently about this history.

George Cruikshank, “The Sick Goose and The Council of Health,” ca. 1831‒1858. Courtesy National Library of Medicine.

Taking epistemological uncertainty of early U.S. medicine more seriously—especially in the radical shift from rationalism to empiricism and the proliferation of worldviews in the medical marketplace during the antebellum decades—could offer more useful accounts of the development of medical knowledge. Still, we don’t know enough about it. Investing perhaps too much in the jeremiads offered by U.S. physicians and experts like Abraham Flexner during the progressive era, many have considered early republican (especially antebellum) medicine as having too little to teach us.[10] We would do well to remember that those narratives were invented by people who were trying to shore up their own professional authority and the truth value of their own epistemology. Even with renewed attention to alternative practices and to medical knowledge produced by Black, Indigenous, and female practitioners, the period is more often described as intellectually stagnant or a nadir for the advancement of medical knowledge—democratization run amok.[11]

So, how else might we narrate the uneven and multidirectional changes in medical knowledge that took place during the early republic? One answer is to reexamine the plots of medical history. In a special issue of Early American Literature on early American disability studies, Cristobal Silva and I called for an approach to historiography based on narrative insights from trauma and disability studies. This approach draws on the work of early Americanists like Kathleen Donegan, who urges us stay with moments of crisis “before the establishment of socially authorized narratives” when history is still “a cluster of unassimilated events,” and that of disability studies scholars like Tobin Siebers, who warns of the fantastical narrative investments inherited from Enlightenment aesthetics that fail to account for experiences derived from varieties of embodiment and cognition.[12] We argued for a historiographical intervention that centers “the textual traces of imprecision, confusion, volatile consciousness, and disordered epistemology,” which offer new insights about the structure of the history and historical epistemology they represent.[13] This is not simply some poststructuralist recognition of the incompleteness of and aporias in all stories but a narrative strategy that refocuses historical narrative on the contested, fragmented, and plural understandings that arise from the lived experience of epistemic crises while resisting the narrative impulse toward resolution.

Applied to medical historiography, such an approach might underscore not only the dislocated, disjointed, and incomplete understandings emerging from disability and trauma but also the idiosyncratic, creative, and inventive aspects of knowledge-making that emerge in and from crisis, whether or not they fit in a neat progressive narrative.[14] As COVID-19 reminds us anew, people living in a crisis rarely understand their experience teleologically. And, given that suffering is central not only to medicine but to human experience, there are also broader historiographical lessons to be gained.

Whiggish histories of medicine (and the popular historical narratives about medicine they promote) fail us spectacularly during crises. Not only do they freeze us in stopped motion, waiting impotently, impatiently, and indefinitely for promised resolution, but they leave little space for the trauma and discomfort of living in a crisis as anything other than a phase to be passed through. Furthermore, because they train us to expect certain kinds of progress, we overinvest in each pronounced medical breakthrough. Then, when a finding is retracted or rapidly revised, the whiplash effect undermines subsequent medical findings, as the dizzyingly uneven and unanticipatable unfolding of knowledge about COVID-19’s transmission, risk, prevention, and treatment shows. The actual messiness of knowledge production is a normal part of medical and scientific research, but during the COVID-19 pandemic, competing theories have risen above debates about empirical facts to the broader level of epistemology. Under the public’s eye, researchers have been forced to grapple not only with emergent knowledge but with debates about what should count as knowledge in a moment of crisis. Better narrative tools to account for this necessary friction not only will provide a more realistic portrayal of medicine in the past but may better secure public faith in medicine in the future.


Endnotes

[1] I introduce the concept of “epistemic crisis” in my book The Medical Imagination: Literature and Health in the Early United States (Philadelphia, 2018).

[2] Stories of creativity in hospital settings and accidental discoveries abound. This is to say nothing of the competing ideas circulating outside of the profession—whether harmlessly anecdotal, as in the case of whether smoking or Advil affect patient outcomes, or deathly serious, as in the peddling of hydroxychloroquine as a miracle cure. Patient advocacy work is underscoring the emergence of “long haulers” whose testimony is changing the temporality of the disease. Moreover the crisis has given more space to alternative practitioners and patient advocacy groups as well as anti-science activists like the anti-vaxxer movement.

[3] Owen Whooley, Knowledge in the Time of Cholera (Chicago, 2013), 5. Also see Bruno Latour’s Science in Action: How to Follow Scientists and Engineers through Society (Cambridge, MA, 1987), 133‒41.

[4] Charles E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge, UK, 1992).

[5] Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago, 1962), 5.

[6] John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 18201885(Cambridge, MA, 1986), 45.

[7] Whooley, Knowledge, 69; Rosenberg, Cholera Years, 155.

[8] For some targeted studies that reveal this uneven change and plurality, see Thomas Apel’s Feverish Bodies, Enlightened Minds: Science and the Yellow Fever Controversy in the Early American Republic (Stanford, CA, 2016); Mark Allan Goldberg’s Conquering Sickness: Race, Health, and Colonization in the Texas Borderlands (Lincoln, NE, 2016); and Whooley’s Knowledge in the Time of Cholera. Joseph M. Gabriel and Bennett Holman track changing “epistemic virtues” in “Clinical Trials and the Origins of Pharmaceutical Fraud: Parke, Davis & Company, Virtue Epistemology, and the History of Fundamental Antagonism,” History of Science (2020), preprint, 5‒10.

[9] David S. Jones, “History in a Crisis—Lessons for Covid-19,” New England Journal of Medicine (Mar. 12, 2020), 1.

[10] See, for example, Abraham Flexner Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (New York, 1910), esp. 3‒20.

[11] Toby A. Appel, “The Thomsonian Movement, the Regular Profession, and the State in Antebellum Connecticut: A Case Study of the Repeal of Early Medical Licensing Laws,” Journal of the History of Medicine and Allied Sciences 65, no. 2 (2010), 153‒86; Elaine G. Breslaw, Lotions, Potions, Pills, and Magic: Health Care in Early America (New York, 2012); Gretchen Long, Doctoring Freedom: The Politics of African American Medical Care in Slavery and Emancipation (Chapel Hill, NC, 2012); Britt Rusert, Fugitive Science: Empiricism and Freedom in Early African American Culture (New York, 2017); James C. Whorton, Nature Cures: The History of Alternative Medicine in America (Oxford, UK, 2004).

[12] Kathleen Donegan, Seasons of Misery: Catastrophe and Colonial Settlement in Early America (Philadelphia, 2013), 6‒7;Tobin Siebers, Disability Aesthetics (Ann Arbor, MI, 2010).

[13] Sari Altschuler and Cristobal Silva, “Early American Disability Studies,” Early American Literature 52, no. 1)[need date], 9.

[14] This is the kind of approach I was after in The Medical Imagination, which is structured around the varieties of creative responses to different epistemic crises in the early republic.

23 September 2020

About the Author

Sari Altschuler is associate professor of English and Founding Director of Health, Humanities, and Society at Northeastern University.

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