This essay attempts to open up our perspective on novels’ use of medical narrative realism. Previous analyses of “medicine and the novel” have focused on a common realist ideal and on novels with medical content. But even a realist methodology shared by the novel and by medicine did not find common expression in both genres. Accordingly, this paper draws on some examples that are representative of nineteenth-century novels and range from literal discussions of disease to scenes much farther removed from literal depictions of medicine or disease, but which still, I am arguing, draw on narrative techniques associated with medical clinical realism for their effect. In fact, novels revised and redirected such techniques, often using them against the grain of the professional ideology from which they arise. Accordingly, this essay will sketch out not only how medical case histories can use supposedly literary techniques, but also how nineteenth-century novels apply the narrative methods of clinical medicine even where medicine is not strictly at issue, and how they adapt those methods to their own literary aims.
Corps de l’article
Victorian clinical medicine usefully referenced a historically specific kind of authority, based on a particular notion of truth, its collection, and its transmission. Clinical methods of observation and representation offered useful and powerful strategies for writers, conveying a sense of rigorous observation, careful description and narration, and professional knowledge. It is evident how useful these might be to novelists facing what Peter Brooks has called the “descriptive imperative” of the nineteenth-century novel (17), since in fact medicine pursued these methods of vision and representation to meet that same imperative in medicine.
While it is my central claim that nineteenth-century literary and medical genres—in particular the novel and the case history—shared important forms of observation and representation, diverging disciplinary norms constrained their use of these elements. Previous analyses of “medicine and the novel” have focused on a common realist ideal and often on novels with medical content. But even a realist methodology shared by the novel and by medicine, as usefully articulated by critics like Lawrence Rothfield, did not find identical expression in both genres. Rothfield identifies “medical realism” as using a clinical or diagnostic voice, and he rhetorically asks if such a discourse “can … help to shape such formal features as point of view, characterization, description, diegesis, or closure, even in the absence of terminology?” He suggests that the answer is yes, noting that “one should be able to find some of these same techniques at work in other realistic novels where doctors and patients do not appear as such or appear only at the margins of the story” (xv, xvii). Indeed, nineteenth-century novels have recourse to a medical methodology even where medicine is not strictly at issue. Novels profitably use these strategies even when they portray neither doctors nor illness. 
If novelists free these techniques of vision and representation from their anchor in medical prose, both medical writers and novelists also revise these techniques in use, adopting them in a manner that contradicts medical authority or norms, or in the interests of literary aims such as sympathy, sentiment, sensation, irony, humor, or morality. The medical case history likewise borrows narrative forms and strategies from the novel, even after the establishment of a normative clinical genre for the case history, and especially in cases where professional knowledge or abilities fail.
Miriam Bailin has argued for a “marginalization of medical knowledge and discourse” in early and mid-Victorian fictional scenes of “illness and recovery,” which she finds uninflected by clinical discursive norms (3). It is also possible, however, that Victorian novelists’ clinical realism may at times be masked by being deployed strategically rather than universally, and often in settings outside that of the sickroom. Thus, despite the useful work by critics like Bailin, Athena Vrettos, Peter Logan, and Maria Frawley, I would like to suggest that it is not necessary to focus on the “illness narrative” in fiction in order to examine the uses of medical realism in the novel. Studying the case history as a narrative genre can help unpack how clinical-realist observation and representation get used not only in, but outside, the realist novel, and not only as part of, but also beyond the illness narrative.
I. Medical Observation and Medical Authority
The physician’s eye, trained to a clinical gaze, often represents in Victorian novels a dispassionate, accurate evaluation, a keener access to reality, like that of a reliable but not omniscient narrator. While the ne’er-do-well father of an injured child, in Margaret Oliphant’s The Rector and the Doctor’s Family (1863), panics so that “his trembling nervous fingers and bemused eyes could make nothing of the ‘case,’” his brother, Dr. Rider, shifts into professional mode even in the midst of his own frustration and anger. “Both father and mother thought [the boy] dead,” the novel comments, “but the accustomed and cooler eyes of the doctor perceived the true state of affairs. Edward Rider forgot his disgust and rage [at the negligent father] as he devoted himself to the little patient—not that he loved the child more, but that the habits of his profession were strong upon him” (87).
What signifies Rider’s authority here is primarily his capability for distanced observation, which he combines with a medical knowledge born of experience (his “accustomed and cooler eyes”) to enable an accurate evaluation of the situation and competent, engaged action. What characterizes the doctor qua doctor here is the training that enables him to overcome himself as character, to submerge his mere individuality, his love, and his rage, and to become a type. “The Doctor” of Oliphant’s title has earned his distinctive social authority by virtue of this particular skill, innately associated with the clinical gaze that Michel Foucault has identified. In fact, it had become an axiom of medical professionalism (although a contested one) that the physician’s knowledge could only be gained by cultivating this distanced view, one that paradoxically also sees more closely. A disinterested medical vision, it was thought, can peer beyond surface impressions to perceive the innermost workings of the body, emulating the anatomical dissections that inaugurated the clinical era.
Ironically, though, Dr. Rider’s distanced gaze is not entirely a Foucauldian one. His authority here is not simply that of a “clinical gaze,” because his diagnostic eye both marks the forced submersion of his inner man and, paradoxically, enhances his humanity. His ability to “forg[e]t his disgust and rage” by losing himself in clinical observation here paradoxically suggests what the narrator must then disavow—that “he loved the child more.” Oliphant is typical of Victorian novelists in her interest here in the relation between two modes of vision: clinical observation and a human insight. While some authors in the medical community considered these incompatible, novelists like Oliphant consider whether one may in fact enable the other.
Nineteenth-century British medical narratives increasingly project a realist medical discourse that both invokes and enacts this cultural authority, that of the disembodied, knowledgeable, and professional eye. The theory and ideology of medicine change in the 1830s, with the medical reform movement and the backlash against “heroic” medicine; but professional medical education and practice do not change greatly until the advent of germ theory and antibiotics late in the century. As a result, much of the progress of professional Victorian medicine occurs through changes to the structure of medical practice, including the representation of that practice in narrative form (the case history). This moves away from the spectacular, curious cases of the eighteenth century toward the dispassionate scientific ideals of the nineteenth.
These newly disciplined narratives are central to the construction of professional medicine. If a physician engages with a case by observing the signs, evaluating them in the light of his previous knowledge (diagnosing the illness), and suggesting action (treating the illness), the clinical case history completes the cycle by returning the product—new clinical experience, whether real or vicarious —to a now-enlarged body of professional knowledge. That is, these narratives invoke the insights of clinical observation through a prescribed narrative form, ritualizing the process of professional judgment, in the process realizing medical knowledge in a new, distinctive way. By combining clinical observation with realist description and narration of experience, physicians had access to a powerful new methodology for producing a professional knowledge and identity. The advantages of a clinical realist methodology proved portable beyond the bounds of the medical narratives for which it was developed.
II. Medical Observation and Representation in the Novel
Given the cultural authority that comes to inhere in clinical medical observation and representation, which together come to evoke an ideal of accuracy and discernment, it is not surprising that novelists turn to it as a tool. It allows novels to describe and evaluate some object, or narrate and judge some process, whether it be a person, a landscape, a social system—or the efficacy of a particular style of housekeeping, the popularity of purchased pastries in a small town, or rumors of a bank failure.  The methodical, diagnostic gaze associated with the clinical close-reading of an object particularly facilitates a consideration of the moral, emotional, or spiritual, as well as physical, state of individual characters or of British society as a whole. However, even inanimate objects such as landscapes, examined this way, may resonate with a kind of diagnosis, and a clinical approach may be adopted even by authors who are ostensibly skeptical about scientific methods.
In Benjamin Disraeli’s Sybil (1845), a novel with a particularly complicated relation to medical culture, the narrator overtly takes on the role of a physician when diagnosing the social ills of the nation as evidenced in the town of Marney, which represents the sorry “condition of the People” of England (193).  The approach to the town appears “delightful” to the untutored traveler, who perceives only its situation “[i]n a spreading dale, contiguous to the margin of a clear and lively stream, surrounded by meadows and gardens, and backed by lofty hills, undulating and richly wooded” (51). This is, however, but a “[b]eautiful illusion,” which the narrator rapidly dispels through authority gained from a kind of dissection, cutting through this superficially “merry prospect” to reveal the decay deep in the body of England. “[B]ehind that laughing landscape,” the narrator warns, “penury and disease fed upon the vitals of a miserable population” (51).
Disraeli’s metaphor explicitly references clinical processes, specifically surgery and dissection. His narrator searches deep to reveal not only the inner organs or “vitals” of England, but the nation’s hidden cancer, “full of pain” in contrast to its outward appearance. Recalling the “traditional epithet of [the] country,” the narrator suggests that England is not so much merry as delirious, displaying a disordered and entirely symptomatic disconnect between face and flesh, appearance and reality, surface and depth. This is clearly a pathological landscape, which to be cured must be opened to the fresh air, and to the reformer’s cleansing scalpel.  In the interests of that healing cut, the narrator deliberately shifts his gaze from one element of the scene to another, bringing to light a series of details, from the general state of the “narrow and crowded lanes” and “cottages built of rubble,” to a catalogue of the disorder in structures such as the “leaning chimneys” and “rotten rafters” (51-52).
Not only does Disraeli adopt the methodology of a clinical examination for this description of a diseased England, he also centers his critique on the actual diseases endangering the inhabitants of this landscape, in a clear reference to the sanitary movement and Edwin Chadwick’s 1842 Report on the Sanitary Condition of the Labouring Population of Great Britain. Chadwick conveyed reports of squalor from medical observers, whose descriptions seem a complete inversion of the “happy valley” above, like the “cancer” that the novel eventually exposes. Mr. Aaron Little, describing the parish of Colerne, comments that “it has an appearance of health and cheerfulness which delight the eye of the traveler… but this impression is immediately removed on entering at any point of the town. The filth, the dilapidated buildings, the squalid appearance of the majority of the lower orders, have a sickening effect upon the stranger who first visits this place” (86). Similarly, Mr. John Fox reports, for example, a house set in “a valley between two hills, very little above the level of the river… [with] an accumulation of filth of every description in a gutter running about two feet from its front, and a large cesspool within a few feet behind.” The inhabitants were “badly fed, badly clothed, and many of them habitually dirty, and consequently typhus, synochus,  or diarrhoea, constantly prevailed” (83).
The novel’s interest, like the physician’s, is in the sites and causes of disease. Disraeli’s narrator also returns again and again to the “open drains full of animal and vegetable refuse, decomposing into disease,” the “foul pits” and “stagnant pools” of “dissolving filth,” just as a physician performing a post-mortem examination would direct particular interest to his dissection of the diseased rather than healthy organs (52). The passage specifically references typhus and malaria and concludes by diagnosing an array of dreaded diseases, including accurate descriptions of “Fever, in every form, pale Consumption, exhausting Synochus, and trembling Ague” (52-3). His capitalization suggests a personification of these fevers, as dread persons haunting the land—a literary touch at the deepest point of the narrator’s surgical exploration, testifying to novelists’ tendency to combine a clinical discursive methodology with more affecting techniques. By combining this memorable figuration of disease with the clinical details of each fever and its cause here, this passage would be especially resonant with a reading public that had endured wave upon wave of epidemic fevers over the previous few decades, and who would thus be familiar with both the personification of disease, and its all-too-material symptoms.
Disraeli’s “case history” of a literally diseased landscape also points to the metaphorical power of clinical narratives in the hands of a novelist. Like the physician-turned-social reformer James Phillips Kay, Disraeli argues here for “England’s social problems as a kind of disease” (Poovey 58). The passage portrays these diseases not only as literal threats but also as potent signifiers of the failures of domestic policy in general, as cancers on the body politic. Although the scene offers the opportunity to fulminate about a number of different moral and social ills—national security, crime, the economy, industrialization and labor relations, and the like—the narrator portrays public health failures in particular, making his argument about the economic and political health of the land, and the consequences for England’s moral and spiritual health.
Ironically, Disraeli is not known for his interest in science and medicine. The “Young England” movement of which he was a member generally scorned the statisticians working on public health, arguing that statistics distance the reader from the true human cost of endemic poverty. Indeed, Mary Poovey argues for Sybil as “a counter to [the] anatomical realism” that she associates with Chadwick and Kay (137).
While individual persons in the scene do suffer from particular diseases, this passage focuses its “diagnosis” on the landscape as a whole. It presents a clinical examination, not of any individual body, but of the landscape and the town, as synecdoches for the nation; and its reference to these fevers suggests how they sap life and health from the economic and social as well as the individual body. The passage offers, then, one example of how nonmedical novelists can demonstrate familiarity with medical observation and representation, and how they can refocus these to diagnose subjects other than characters. Indeed, rather than simply depicting and diagnosing the diseases of particular characters, the clinical perspective here examines and evaluates a social function; clinical observation and narration function as the mode of argument of the novel. The narrative is itself structured by and oriented toward a clinical perspective, rather than merely recording some character’s use of that perspective; and clinical observation and narration become a mode of representation rather than simply being represented.
A novel may thus strategically employ a technique drawn from medicine, without the plot—or the novelist—being particularly invested in medical or scientific culture. Acknowledging the uses of medical realism beyond direct experience usefully opens up the available field of analysis beyond George Eliot, Charles Dickens, Sarah Grand, and others with established personal connections to the medical or scientific community.
The case history offers Victorians a unique relation to the genre of scientific realism more generally. Elements of the medical community asserted the role of medicine as an “art” more fiercely every time medical statistics and clinical science crested a new wave of popularity. As a result, case histories are more likely than other kinds of scientific texts to attempt a balance, albeit an uneasy one, between science and art, observation and insight. 
Medicine’s ambivalence about science, and its reluctance to give up its status as an “art” means that Disraeli’s depiction of the diseased town can draw strategically on clinical practice here to inform his condemnation of a diseased social environment, without entirely adopting or accepting the impersonality of clinical science. By using medical tropes such as cancer and fever to frame his description of rural poverty, Disraeli gives bite and specificity to his critique. And when his narrative combines medical practices such as diagnosis and dissection, with more evocative descriptions of England’s pathology, he can propose a reformist approach that combines a critical observation of environment with the human insight that must accompany any practice of the medical art.
III. Literary Representation and Insight in Medical Narratives
While novelists made use of medical techniques of observation and representation, Victorian physicians did not entirely eschew literary techniques in writing case histories, even as the genre became more formal and less elastic in order to promote the scientific and professional aims of medical practice. Despite the demands of increased hospital training for students, literary reading remained central to physicians’ reputation as men of letters. For instance, Edward Forbes argues in 1843 for the importance of literary and aesthetic subjects even in medical school. While the medical profession “must become more and more scientific every day,” he warns, “[t]he air of a hospital is mentally unwholesome, unless mingled with a full proportion of collegiate atmosphere. The very neighbourhood of literary and scientific studies has a purifying and elevating effect on the mind of the student” (11). Thus, he concludes, the aim of a proper medical education must be to produce a physician who is at once “a scholar, a man of science, and a man of taste; and, above all, imbued with sound principles of religion and morality” (12). Forbes is echoing a widespread concern that physicians must continue to read literary texts, to retain not only their status as men of culture, but also their professional acumen.
The physician’s elevated status over surgeons, apothecaries, and irregulars had traditionally been due in part to his university training, little of which was required to be scientific until a medical school entrance examination on physics, chemistry, and biology was instituted in the 1880s (Peterson 60). Although the divisions between the ancient “corporations” (physician, surgeon, apothecary) diminished after the Medical Reform Act of 1858, which created a list of all licensed practitioners, new distinctions arose between provincials and their metropolitan colleagues, whose status as consultants and fellows of the professional societies were still often supported by a liberal education. The criteria for Fellowship in the Royal College of Physicians as late as 1882 included “not only ‘Professional Eminence’ and ‘Distinction in ... Science’ but also ‘Distinction in Literature’ and ‘Social Position’” (Peterson 173).
Thus the author of an 1846 article in the Dublin Medical Press, referring to recently released statistics, decries the absence of bookshops in some areas of Ireland, so that “there are many [towns] in which the medical practitioner can find neither book nor journal to enable him to keep his mind in a state of cultivation and his information equal to that of others more favourably circumstanced.” The article examines “medical bookselling” separately, explaining that “the fatal mental repose which the absence of literary food and stimulus induces extends to this department” (“Literary Tastes” 413, emphasis in original).
Literary norms and strategies, even those of the devalued form of the novel, would thus have been familiar to most physicians as readers. Indeed, cases even late in the century testify to their continued influence. The physician Byrom Bramwell published as late as 1890 a “Case of So-called Perforating Tumour of the Skull” in which a large part of the history and examination are presented in dialogue with the patient’s mother (the patient was a four-year-old boy). The boy presented with his left eye discolored and protruding from its orbit, and with an orange-sized lump on his head. Bramwell cross-examines the mother while instructing his students in the case.
Dr. B. (to the patient’s mother). How long is it since you noticed the lumps on the boy’s head?
Patient’s mother. Three weeks yesterday.
Dr. B. How long has his eye been like that?
Patient’s mother. Six or seven weeks ….
Dr. B. (to the Students). The head is large.
Patient’s mother. He always had a large head.
Dr. B. Did you notice anything wrong with his head before the lumps appeared?
Patient’s mother. No, there was nothing wrong with his head till three weeks ago.
Dr. B. Was he quite well till three weeks ago?
Patient’s mother. Yes. He was a strong healthy child. We noticed nothing the matter with him till three weeks ago.
This interactive, inefficient manner of presenting the facts of the case is unusual, even in a book like this, reporting pedagogical lectures. In fact, dialogue had not been a normative part of medical representation since the eighteenth century, when it was derived from the philosophical genre of the Socratic dialogue. By 1890, when Bramwell is writing, a distanced, terse, third-person prose had long constituted the normative discourse of a medical case history. Educated and practicing in Edinburgh, a center of British medicine, Bramwell, who later was knighted for his contributions to medicine, was already a Fellow of the Royal College of Physicians of Edinburgh, an instructor of medical students at the Edinburgh Royal Infirmary, and the author of a textbook and other writings on medical diagnosis and “case-taking.” His decision to present this case in dialogue is unlikely to follow from ignorance of the norms of medical representation.
Rather, this dialogue presents a striking pedagogical demonstration of how human emotion and error often obscure the true history of an individual case of disease, and how to elicit this history from a lay interlocutor. Further examination brings out what Bramwell calls “the confusion in the mother’s statement” about the progress of the disease (250). He eventually ascertains that the boy’s eye had become discolored six or seven weeks previously, he’d complained of headache a few weeks later, and then had become seriously ill with the appearance of the lumps.
Bramwell’s presentation in dialogue emphasizes the performative nature of the diagnostic process and cannot help but resonate with literary portrayals of the anxious, loving, ultimately helpless mother. Despite Bramwell’s dispassionate reportage, her distress appears in her confusion over the dates, her denial of anything untoward about the child’s swollen head (“He always had a large head”), and her insistence that he was a “strong, healthy child” despite evidence that he’d been sick for some months (in fact, the left eye had been more prominent since birth).
As with many medical case histories that flirt with literary techniques, Bramwell’s prose seems to tolerate the incursion of dialogue in part because this fatal case draws attention to the limits of medical knowledge and skill. It is this kind of fascinating juxtaposition of discourses that allows the genre of the case history to interrogate the development of “properly” literary and medical narratives.
As a result of this discursive hybridity, case histories can become porous to alternate methods of observation as well as representation. While the case above resists overt sentiment, a space for insight does sometimes open in Bramwell’s cases when he comments on the human circumstances of his patients, as with this patient with aneurysm:
This patient is very poor; he lives in lodgings with his wife; his rent is with difficulty paid; and yet he is not willing to come into hospital. He has not definitely told me so, but I suspect that his reason is this: he knows that if he comes into hospital his house will be broken up, and his wife will have to go to the Workhouse. He wants, I suspect, to avoid that as long as possible. Now that is a plausible reason, and moreover, a reason which we can not only sympathise with, but also admire.“Case Illustrative” 119
The irony is strong here, for the patient will likely die without proper care. Although his professional knowledge argues that the patient is at risk outside the hospital, Bramwell voices his sympathy for him and his difficult choice. “I do not, under the circumstances, feel myself justified in pressing him too strongly to come into hospital,” he concludes (119).
Bramwell’s work suggests that, like many physicians, he cultivated an interest in the form and effect of medical representation. He sometimes notes the “beautiful” example a case presents of its particular diagnosis (“So-called” 252; “Stricture” 200). He is remarking, of course, on how perfectly these individual presentations exemplify the general type, but his choice of terms inevitably implies a kind of aesthetic of medical form.
Bramwell also displays his awareness of literary concepts such as suspense and irony, and structures his cases to make the most of these. In one case, he tells the story of a servant girl who mysteriously died overnight, after a brief illness, and was thought to have been poisoned (“Stricture”). In the case of the impoverished young man, above, he describes the “peculiar and puzzling” pulse that the patient exhibited (“Case Illustrative” 115). Using his skills, training, and tools, Bramwell takes on the role of medical detective in these cases, proving the servant girl to be suffering from perforated ulcer, and the young man from aneurysm, distorting the true pulse sounds. In both cases he reports the history in such a way that his readers must follow in his footsteps from perplexity and suspicion to certainty. He concludes by offering and confirming his diagnoses, bringing closure to these cases, with evidence provided by clinical technology (post-mortem examination and the sphygmograph, respectively). Despite his reliance on clinical technology, the narrative structure of suspense and resolution promotes an appreciation of the physician’s human insight as much as his clinical observation.
While these cases deftly manipulate a pattern of suspense and release familiar to readers of novels, another case displays Bramwell’s acute sensitivity to irony. His “Remarkable Case of Euphoria” details the condition of a friend of his, an officer (physician) in the Indian Medical Service. This friend manages to remain cheerful and unaware of his fatal abdominal tumor even as it develops from “a small hard tumour about the size of an egg” to “a large tumour, fully the size of a child’s head, of great hardness, and evidently malignant,” one day before his death. Bramwell emphasizes both the irony and the unlikelihood of the situation, pointing out that “[b]oth the patient and his wife seemed amazed when the presence of the tumour was pointed out to them.” “How it could possibly have escaped the attention of the patient, a most cultured and intelligent medical man, I am utterly unable to conceive,” he continues, “for it was impossible to place the hand on the abdomen without at once recognizing the large tumour and its dense, hard character” (58). The irony here points to a human insight that drives this case history: the case is really not about the heavy tumor, which is unexceptional, but about this patient’s “remarkable” evasion of the unbearable weight of his own mortality. 
Bramwell’s subtitle for this collection identifies these cases as “some of the more interesting” ones in his experience.  It is not unusual for such curious cases to call forth a narrative that can escape the clinical norms set forth by nineteenth-century physicians. In fact, it is possible that the literary forms evoked here help to normalize or naturalize cases that otherwise disturb the case history—the narrative site of medical professionalism—particularly when these cases call attention to the boundedness of medical knowledge and practice.
IV. Complications of Discursive Hybridity
When novels import visual and representational norms from other disciplines, the resulting discursive hybridity not uncommonly both supports and undercuts the disciplinary ideologies underlying those norms. Novels and cases can acknowledge but also trouble the norms of literary and medical writing, testifying to a continuing, largely unacknowledged rapprochement between these forms even while physicians were instructed to strive for a clinical discourse and novelists like George Eliot were chided for employing a “medical habit.” And although professional literary and medical writing are conceived of as antipathetic, they are not infrequently combined and even used against the grain of their native ideology.
Although the passage from Sybil, above, does not challenge the medical authority by which the narrator pronounces England diseased, a clinical discourse is not uncommonly both affirmed and undercut in the same novel, or even the same scene. Indeed, while the Victorian novel can apply medical observation as an evaluative tool, it often puts this common methodology to use with an aim or context that is not necessarily congruent with the strict skepticism and anti-subjectivity valorized by medical ideology. Such a conjunction of distinct aims is less welcome in, if not entirely absent from, the nineteenth-century British case history, where physician authors are inclined to preserve the authority of the medical discourse that secures their cultural capital. When novels import visual and representational norms from other disciplines, however, the resulting discursive hybridity can destabilize the disciplinary ideologies underlying those norms.
Thomas Hardy, in the short 1872 novel Under the Greenwood Tree, both deploys and ironizes a medical observation, in a scene of diagnosis early in the novel. This clinical way of seeing temporarily confers a discursive authority on Mr. Penny, the shoemaker, in a scene reminiscent of the demonstrations in a teaching hospital, where the physician instructor would lead the students through the basics of patient history, examination, and diagnosis.  Ironically, Hardy’s shoemaker performs his clinical expertise on two telling, but unlikely, patients: a shoemaker’s last and a boot, which—under his expert gaze—yield crucial information about the symptoms and traumas of their owners. “Now whose foot do ye suppose this last was made for?” he asks his audience of villagers rhetorically, before launching into a demonstration of what can only be deemed professional knowledge:
“It was made for Geoffrey Day’s father [Penny explains], over at Yalbury Wood. Ah, many’s the pair o’ boots he’ve had off the last. Well, when ‘a died I used the last for Geoffrey, and have ever since, though a little doctoring was wanted to make it do. Yes, a very queer natured last it is now, ‘a b’lieve,” he continued, turning it over caressingly. “Now you notice that there”—(pointing to a lump of leather bradded to the toe), “that’s a very bad bunion that he’ve had ever since ‘a was a boy. Now this remarkable large piece” (pointing to a patch nailed to the side), “shows a’ accident he received by the tread of a horse, that squashed his foot a’most to a pomace. The horseshoe came full-butt on this point you see.”24
Although Penny is displaying the expertise proper to his craft as a shoemaker, what he offers here is a particular kind of evaluation, usually associated with a different craft altogether. This mode of evaluation most resembles diagnosis, which had in the nineteenth century become an important feature of medical practice.  The shoe last is curious, “queer natured,” and requires “doctoring.” Penny offers its case history in brief for the men. With its bradded leather lump and nailed-on patch, it is symptomatic of a history of pathology, whether the suffering be chronic and quotidian (the bunion) or extraordinary (horse accident). It acquires its various patches (its brads and nails) violently, in tandem with the injuries to the body. The shoe last thus stands in metonymically for the foot itself, and Penny expertly reads its symptoms, correlating each to its cause and commenting on the distinguishing marks in an almost pedagogical manner, with his audience circled around him respectfully, like medical students in an operating theatre watching a surgeon discourse on a difficult case. The shoe last represents the patient; and Penny’s dispassionate, informed gaze on it, his expert reading of its symptoms and their causes, confers a certain authority on him. A specifically medical methodology is suggested throughout this scene by Penny’s easy air of expertise and specialized knowledge of the trajectory of the lived-in body, his descriptive interest in physiological peculiarities marking that trajectory (a bunion, a “squashed” foot and other “deformed” aspects of the body), and his activity in what Hardy terms “doctoring” and “operating” upon his subjects.
While Hardy allows Penny’s presentation of his expertise to stand largely intact, he also uses humor to undercut it. Ironically juxtaposing Penny’s dialect with the narrative counterpoint, he notes that Penny’s hand, as if unconnected to or uncontrolled by the man himself, “wandered” to the cider-cup and brought it up to his lips, cutting off Penny’s words in a rebuttal of his apparent mastery.
But Penny’s authority is also reasserted after this moment of uncertainty, suggesting that his audience’s thirst for knowledge, and Hardy’s interest in exploring the strategy of diagnosis, is apparently unquenched. For when Penny offers a further object for discussion, “a boot—small, light, and prettily shaped—upon the heel of which he had been operating,” he garners even more fascinated attention (25). It is the boot of the new schoolmistress, Miss Fancy Day. Penny’s disquisition on Geoffrey and his shoe last serves only to frame an approach to the real object of interest, his daughter. While “the eyes of three or four” men only had watched Penny produce the wooden last, “all” of the assembled men focus their gazes avidly on the boot. Indeed, their “glances … converged like wheel-spokes upon the boot” (24-5), in an approximation of the way in which the narrative’s own focus will soon sharply narrow down into an examination of Miss Fancy Day and her amours. Significantly, just as the scars and symptoms of the body (and its shoe last) record the lived experience and inclinations of that body, the size, shape, and condition of the boot leather metaphorically report upon the experience and inclinations of its owner.
The shift from foot, to last (formed on the foot), to boot (formed from the last) takes Penny into territory seemingly less grounded in material evidence. Indeed, at this point learned Spinks, in the audience, challenges his authority. Penny claims that the family “likeness between this boot and that last,” between the “deformed” foot and the “pretty” one, attests to his expertise, since “no common eye can see it” but only “a man in the trade can see the likeness between this boot and that last.” “To you, nothing;” he modestly avers, “but ‘tis father’s voot and daughter’s voot to me as plain as houses” (26). Spinks, however, dismisses the likeness as “mild” and “fantastical,” due to nothing but “imagination.”  Penny maintains his privileged position, however, by explaining how he identified the dead body of John Woodward’s brother through the likeness of their feet, and Spinks reluctantly acknowledges that a further relation can be seen between “a man’s foot” and “that man’s heart” (26).
This picturesque scene offers a remarkable layering of representation upon representation, inviting a reading that, like Penny’s, delves down through multiple layers of reference. Not only does the shoemaker’s last speak of the history of Day’s foot, but Day’s foot speaks of his character, in a preview of the way Miss Fancy Day’s boot and foot promise to reveal hers. This chain of representations, like the novel, mediates between one figurative relation and another, and between the object at hand (the last, and the boot) and the ultimate object of interest (Miss Fancy Day’s character).
Medical observation and its authority are useful to Hardy here because, within such a complex web of suggested significance, they enable the reading of less tangible realities, in an allegorical reading of character. The narrator, too, takes on this diagnostic mode of observation, which frames and enables his delicate examination of Miss Fancy Day’s character, which is the central object of inquiry in this novel.
There, between the cider-mug and the candle stood this interesting receptacle of the little unknown’s foot—and a very pretty boot it was. A character, in fact—the flexible bend at the instep, the rounded localities of the small nestling toes—scratches from careless scampers now forgotten—all, as repeated in the tell-tale leather, evidencing a nature and a bias.26
Fancy may be at this point “the little unknown,” but her character is both foreshadowed by her name and circumscribed by the ambivalent qualities evident in her boot: pretty, flexible, childlike and “nestling,” “careless” or even thoughtless, energetic and not entirely demure (as is suggested by “scampers”) and unreflective (as these scampers are “now forgotten”). The boot itself is “light” of foot; not only nimble of foot but also, perhaps, footloose. Under the directed examination of the narrator, the boot reveals itself, and by extension its owner, as playful, unencumbered, easily influenced, and difficult to steady, perhaps even inconstant. The “tell-tale” leather thus records Fancy’s “nature” and her “bias” as clearly as her father’s shoe last reports on his hardworking life, although, as often occurred with physical symptoms in the era before germ theory, the definitive diagnosis must be deferred.
The novel centrally pursues just this question of Fancy’s possible lightness of character, asking its readers which of the two, Fancy or Geoffrey, is more truly “deformed.” Hardy thus implies that his novelistic process is founded upon, and requires of readers, this kind of diagnosis, in which only a careful, disinterested observation will suffice to read and evaluate the surfaces his characters present to us. Notably, for Hardy (as for George Eliot and many other novelists), rather than trying to separate clinical observation from human insight, as clinical scientists ideally would, a dispassionate visual examination of the material object may actually combine with, or enable, a valuable human insight into its reality.
The penetration of this expert gaze becomes evident when the narrator’s description of the boot, above, unexpectedly informs the examining gaze and thoughts of young Dick, who “surveyed [the boot] with a delicate feeling that he had no right to do so without having first asked the owner of the foot’s permission” (26). The examination the boot has undergone, like a medical examination, exposes more of the private person than is proper before strangers. Typically, however, this observation is also undercut by the novel, since Dick is in fact able to command little confident knowledge of Fancy, with whom he promptly, and foolishly, falls in love. Although the story ends with a happy scene of marriage, Dick, the villagers, and the reader have been kept constantly at fault, forced to re-read and re-evaluate Fancy’s actions for some insight into her footloose inclinations and the circumstances that can turn them toward or away from her faithful lover.
The story thus ultimately suggests that the distanced, penetrative observation associated with clinical medicine is both necessary and fallible before the powerful confluence of character and circumstance. Although no physicians or apothecaries are literally present, the scene suggests a specifically medical methodology by Penny’s easy air of expertise and specialized knowledge of the trajectory of the lived-in body, his descriptive interest in physiological peculiarities marking that trajectory (a bunion, a “squashed” foot and other “deformed” aspects of the body), and Hardy’s choice of the terms “doctoring” and “operating” to describe what Penny does upon his subjects. Even the Woodward anecdote, confirming Penny’s ability to read and identify a foot, alludes to the doctor’s tasks at the end of life: to read and identify the body of the dead man.
Geoffrey’s last and Fancy’s boot, which frame Hardy’s story, thus demonstrate the symbolic potential of medical discursive techniques in a narrative. They foreground questions of authority and expertise, of observation and interpretation, and of the accumulated marks that write the narrative of lived experience on an individual body and spirit. They also set off a troubling resonance in the narrative as it progresses. Both the last and the boot are records or representations of the individual lives they stand in for. But both present problems of authority. “I don’t care to mend boots I don’t make,” Penny comments of Fancy’s boot, implying a difficulty in adequately knowing and then “doctoring,” or “operating” on any subject for which he does not have the solid type—the last—at hand. The last seems more an authority to him than her foot itself, which is available to him. So while Day’s last is of course a stand-in, a replica or reconstruction of the living, changing foot, Fancy’s boot, like her character, seems even more ungrounded, less knowable: it is a mere mold of an absent last, which was made by an unknown authority, and is thus thrice removed from her foot itself, in a chain of signifiers that both enables and impedes reliable diagnosis. The boot is also, however, telling—“tell-tale”—in a way her foot itself would not be. Regardless, the diagnosis of Fancy’s foot, assured as it was, and accurate as it proves to be, must take into careful account the triple mediation in the text, whereby Fancy’s character, as it is revealed by her lived experience, is represented and re-represented, and requires a constant state of re-evaluation and assessment.
I do not mean to suggest that all instances of close examination in the novel should be understood as diagnostic readings. Hardy draws on a variety of descriptive modes to round out his portrait of rural village life. For instance, he often sets the scene with recourse to a botanical vernacular, to use Amy King’s term, as with the opening of the chapter “A Confession”:
Fuchsias and dahlias were laden till eleven o’clock with small drops and dashes of water, changing the colour of their sparkle at every movement of the air; and elsewhere hanging on twigs like small silver fruit. The threads of garden-spiders appeared thick and polished. In the dry and sunny places dozens of long-legged crane-flies whizzed off the grass at every step the passer took.128
After this scene’s record of natural history at high summer, Fancy is surrounded by early apples and butterflies, birds and hollyhocks, in a synecdochal enunciation of her bloom and a descriptive articulation of rural Wessex. Alternately, when Dick is attending on Fancy, who is interminably sewing on her dress, the narrator offers a masterful bit of “business” dramatizing the bored, waiting suitor. “Dick arose from his seat, walked round the room with his hands behind him, examined all the furniture, then sounded a few notes on the harmonium …. [He] fidgeted about, yawned privately, counted the knots in the table, yawned publicly, counted the flies on the ceiling, yawned horribly.” (140). Neither of these instances draws on medical realism, but they establish the dominance of visual examination in the novel, and they work together with instances of clinical observation to ground and authenticate Hardy’s imagined world.
As should be evident by Hardy’s complicated use of the trope of professional examination and diagnosis, a novel’s adaptation of medical discourse often resists simple reading. Even novels that adopt a clinical discourse do not spurn all affect, as physicians were at one point advised to do, or affect a coldness or disinterest in human character. On the contrary, this is one of the predominant ways in which novels differ from case histories in using medical discourse. Esther Summerson’s competent, experienced eye enables her deftly, single-mindedly to detail the symptoms of an ill-run household during her visit to the Jellybys in Dickens’s Bleak House. Her narrative notes the “tarnished” nameplate, “litter” in the rooms, “marshy” atmosphere, unkempt curtains, rumpled and torn stair-carpets, uncooked dinner, and above all the injured and filthy condition of little Peepy, who had fallen down the dark, ill-kept stairs and is superbly ignored by his mother (51, 52, 55). All these symptoms would mean much within the mid-century discourse on public health, or to any reader familiar with contemporary theories of domestic hygiene. However, this enumeration does not register an emotional distance from the situation (like Penny’s), as might be suggested by the act of diagnosis. Rather, it only intensifies Esther’s—and presumably the reader’s—pity for Peepy. Ultimately, the focused, diagnostic, clinical detail of medical observation can be deployed to much greater variety of effect in the more forgiving contexts of a novel than it can in a Victorian case history.
Medical observation in the novel does not necessarily remain unchallenged. Penny’s expert demonstration only momentarily allows him to assume diagnostic authority, and the suggestive diagnosis of Fancy is, in fact, in question throughout the novel. However, Geoffrey’s last and Fancy’s boot demonstrate the symbolic potential of medical practices in a narrative. They foreground questions of authority and expertise and of observation and interpretation, even when they are ironized, undercut, or used upon apparently trivial objects. The trope of medical diagnosis enacted here, composed as it is of a blend of observation and insight continuously under revision, thus acts as a groundwork for a complex meditation on structures of authority and on the limits of human knowing, central questions for Hardy and for the Victorian novel as a whole.
- While I agree with Rothfield that clinical discourse is indeed in play in novels beyond Middlemarch, I would like to extend his analysis. Indeed, as I have argued elsewhere, realist novels are hardly alone in finding a medical narrative methodology relevant and useful, if only for a partial, momentary, or even critical adoption. (See Kennedy, “Ghost in the Clinic.”) It is no surprise that Gothic novels often draw upon medicine, given the nineteenth-century tradition of the scientific Gothic. But sentimental and sensation fiction can also reference this realist methodology; and clinical medical narratives, despite their skepticism, continue to draw from these non- or even anti-realist subgenres. That is, clinical medicine offered a useful cultural resource for a range of literary authors and audiences, even when they did not fully subscribe to its tenets, because clinical discourse usefully referenced a historically specific kind of authority, based on a particular notion of truth, its collection, and its transmission.
- See Shapin and Schaffer’s discussion of the scientific report’s origin as a means of replicating experiments for a wider audience, providing a kind of virtual audience for the experimenter and a virtual experience for the reader. Although eyewitnesses were no longer, by the mid-nineteenth century, crucial as testimonials to the authenticity of the experiment, as they had been in the seventeenth century, the purpose of the scientific report remained to certify individual experiences as professional, and thus communal, knowledge. See also Daston, “Objectivity.”
- These examples are drawn from Charles Dickens, Bleak House; George Eliot, “Brother Jacob”; and Margaret Oliphant, Hester.
- He uses this phrase throughout the novel, as well as in the Advertisement at the beginning.
- Disraeli thus literalizes the imperative that Pamela Gilbert identifies in mid-century medical mapping: to open up and illuminate the dark spaces of poverty. See Gilbert, Mapping 27-54.
- Synochus is a continued fever, meaning not remittent or intermittent; the term was little used after the 1840s.
- Recent analyses of the case history by Janis Caldwell and Jason Tougaw consider medicine’s dual allegiance to both science and art.
- It is rare, but humor also surfaces in the case history, as in John Elliotson’s report of the case of a single woman in her thirties with an abdominal disorder, who adamantly denied the mere possibility of pregnancy: “She had a pulse of 80; something within her had a pulse of 128; and what that was, I left her to settle by herself. All that I could say was, that if she waited patiently, the whole of the disease would come away, to a certainty, in two or three months” (61).
- The full title is Studies in Clinical Medicine, a record of some of the more interesting cases observed, and of some of the remarks made, at the author's out-patient clinic in the Edinburgh Royal Infirmary.
- As Peter Mere Latham explains to students, his role as a hospital lecturer is that of a “demonstrator of medical facts”: “engaged to direct the student where to look for, and how to detect, the object which he ought to know; and, the object being known, to point out the value of it in itself and in all its relations” (27). This is precisely what Penny does for his auditors.
- Diagnosis was much less important in eighteenth- and early-nineteenth-century medicine, when treatment was largely symptomatological anyway. Indeed, when George Fordyce constructed a chart to be used “to improve the evidence of medicine” in 1793, he included space to record just about everything about a case and its progress—time, symptoms, climate, treatments—except diagnosis. However, as knowledge about distinct diseases (different sorts of fevers, for example) advanced, diagnosis became more useful to the physician in determining treatment.
- It is symptomatic of Spinks’s relatively limited knowledge that he supposes “imagination” to be utterly foreign to the process of acquiring and deploying professional knowledge. The role of imagination, or hypothesis, in science had inspired fervent discussions, garnering support from the likes of William Whewell earlier in the century, and Claude Bernard and John Tyndall, in the decade just before this novel appeared. See Whewell, Bernard, and Tyndall’s “Discourse on the Scientific Use of the Imagination,” an address to the British Association for the Advancement of Science in 1870.
She is Assistant Professor at Florida State University, studies Victorian medicine and science, theory and history of the British novel, visual culture, and fiction of empire She has published articles on Gothic medicine, the New Woman novel, and imperial medicine. This essay is adapted from the introduction to her current book project, which reads nineteenth century British medical case histories against developments in the British novel and is titled Rewriting the Clinic: Vision and Representation in Victorian Medicine and the Novel.
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